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AmeriGroup Disclosure of Ownership and Control Interest Statement  Form

AmeriGroup Disclosure of Ownership and Control Interest Statement Form

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Causes to be made a false statement or representation of this statement may be prosecuted under applicable federal or state laws. Amerigroup RealSolutions DISCLOSURE OF OWNERSHIP AND in healthcare I CONTROL INTEREST STATEMENT Identifying Information Name of Entity Business Address City State ZIP Phone II Answer the following questions by selecting YES or NO. D Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities Example sole proprietor partnership or members...
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