UnitedHealthcare Community Plan Provider Disclosure Form

UnitedHealthcare Provider Entity Disclosure of Ownership, Controlling Interest and Management Statement

Individual providers please use social security number; field cannot be left blank: “N/A” non-applicable and “applied for” are acceptable responses.

UnitedHealthcare Community Plan (“UnitedHealthcare”) is required to collect disclosure of ownership, controlling interest and management information from providers that participate in the Medicaid and/or the Children’s Health Insurance Program (CHIP) managed care network pursuant to a Medicaid and/or CHIP State Contract with the State Agency and the federal regulations set forth in 42 CFR Part §455.

Completion and submission of this Statement is a condition of participation in the Medicaid and/or CHIP managed care network and is a contractual obligation with UnitedHealthcare for services to members under Medicaid and CHIP benefit plans.

This Statement should be submitted with the initial contract and updated every three (3) years or at the renewal of the contract and at any time there is a revision to the information or upon a request for updated information.

Detailed instructions and a glossary for capitalized terms can be found at the end of this form. If attachments are included, please indicate to which section those attachments refer.

Contracted Provider Entity Information

Please fill out the entire section. Every field must be complete.

Legal Name (“Provider Entity”):

DBA Name (if different from Provider Entity Legal Name):

Complete Address (must include at least one street address):

Street City State Zip

Additional Addresses (list all Practice locations) Yes No

Section I: Identification of All Owners

Are there any individuals or organizations with a Direct or Indirect Ownership of 5% or more in the Provider Entity? Yes No

Do you have a list to attach? Yes No

If yes, list the name, primary address, date of birth (DOB) and Social Security Number (SSN) for each person/organization having a Direct or Indirect Ownership Interest in the Provider Entity of 5% or greater.

Section II: Identification of All Individuals & Entities with a Controlling Interest

Board of Directors: Does the Provider Entity have a Board of Directors or other governing body? Yes No

Officers and Directors: Does the Provider Entity have any officers or directors? Yes No

Are there any other individuals or entities with a Controlling Interest in the Provider Entity? Yes No

Section III: Ownership & Controlling Interest in Other Disclosing Entities

Do any of the individuals or entities identified in Section I have an Ownership or Controlling Interest in any Other Disclosing Entity? Yes No

Section IV: Ownership & Controlling Interest in Subcontractors

Does the Provider Entity have a Direct or Indirect Ownership Interest of 5% or more in any Subcontractor? Yes No

Section V: Familial Relationships

Are any of the individuals identified in Sections I, II, III or IV related to each other? Yes No

Section VI: Criminal Convictions, Sanctions, Exclusions, Debarment and Terminations

1. Has the Provider Entity, or any person who has an Ownership or Controlling Interest in the Provider Entity, or who is an Agent or Managing Employee ever been convicted of a crime related to Medicaid, Medicare, CHIP, or Title XX? Yes No

2. Has the Provider Entity, or any person who has an Ownership or Controlling Interest, or who is an Agent or Managing Employee ever been sanctioned, excluded or debarred? Yes No

3. Has the Provider Entity, or any person who has an Ownership or Controlling Interest, or who is an Agent or Managing Employee ever been terminated from participation in Medicaid, Medicare, CHIP or a Title XX program? Yes No

Section VII: Business Transaction Information

Business Transactions - Subcontractors: Has the Provider Entity had any business transactions with a Subcontractor totaling more than $25,000 in the previous twelve (12) month period? Yes No

Significant Business Transactions – Wholly Owned Suppliers: Has the Provider Entity had any Significant Business Transactions with a Wholly Owned Supplier in the past five (5) year period? Yes No

Significant Business Transactions – Subcontractors: Has the Provider Entity had any Significant Business Transactions with a Subcontractor in the past five (5) year period? Yes No

Section VIII: Management & Control

Managing Employees: Does the Provider Entity have any Managing Employees? Yes No

Agents: Does the Provider Entity have any Agents? Yes No