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Get and Sign Kansas Disclosure 2016-2022 Form
Disclosure of Ownership and Control Interest Statement must be submitted upon enrollment upon executing a provider agreement/contract upon request of the Medicaid agency during revalidation and within 35 days after any change in ownership of the disclosing provider entity. Fill in each section. Every field must be complete. If fields are blank or the form is unreadable e.g. due to illegible handwriting the form will be returned for corrections/completeness and not processed. Instructions for...Show details
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