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Disclosure of Ownership and Control Interest Statement CDPH 276 D  Form

Disclosure of Ownership and Control Interest Statement CDPH 276 D Form

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Instructions and help about Disclosure Of Ownership And Control Interest Statement CDPH 276 D

In this video we'll provide pertinent information about important fields in the Disclosure of Ownership and Control Interest Statement and the Principal Information Form or PIF 2 Form. On Provider Enrollment on the Portal or PEP. Let's start with the Disclosure of Ownership and Control Interest Statement, under type of entity select only one entity. The entity selected must match the entity selected on the W9. If the selection on the W9 is not one of the options in this section. Utilize the Other Field and input the correct value. Under 501 (c) (3) Internal Revenue Exemption. If yes is answered submit a copy of the IRS exemption letter. Total Direct ownership should equal at least 100%. If this is not the case, you the provider must submit an explanation in writing on company letterhead, that explains why the total ownership does not equal 100 percent. This excludes Government-Owned Providers i.e State, County, and City Providers. If an entity is listed as the sole 100% owner, the prov

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