Instructions for "Provider Disclosure Statement Form" - Delaware

This document was released by Delaware Department of Services for Children, Youth and their Families and contains the most recent official instructions for Provider Disclosure Statement Form.

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Download Instructions for "Provider Disclosure Statement Form" - Delaware

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State of Delaware
The Department of Services
For Children, Youth and
Their Families
Instructions
If you cannot report all of the necessary information in a designated section of the form because
of space limitations, please provide the information in the optional remarks section. The optional
remarks section will allow you to enter up to 500 characters. It is located near the end of the form
just above the signature line.
All required fields must be completed (with no blank lines between reported information).
Terms
Drop down field refers to a field containing the
symbol.
Definitions
Agent means any person who has been delegated the authority to obligate or act on behalf of a
provider.
Disclosing entity means a provider (other than an individual practitioner), or a fiscal agent.
Any entity that does not participate in Medicaid, but is required to disclose certain ownership and
control information because of participation in any of the programs established under title V,
XVIII, or XX of the Act means:
a. Any hospital, skilled nursing facility, home health agency, independent clinical
laboratory, renal disease facility, rural health clinic, or health maintenance organization
that participates in Medicare (title XVIII);
b. Any Medicare intermediary or carrier; and
c. Any entity (other than an individual practitioner or group of practitioners) that furnishes,
or arranges for the furnishing of, health-related services for which it claims payment
under any plan or program established under title V or title XX of the Act.
Fiscal agent means a contractor that processes or pays vendor claims.
Group of practitioners means two or more health care practitioners who practice their profession
at a common location (whether or not they share common facilities, common supporting staff, or
common equipment).
Indirect ownership interest means an ownership interest in an entity that has an ownership
interest in the disclosing entity. This term includes an ownership interest in any entity that has an
indirect ownership interest in the disclosing entity.
Individual practitioner means a physician or other person licensed or certified under State law to
practice his or her profession.
State of Delaware
The Department of Services
For Children, Youth and
Their Families
Instructions
If you cannot report all of the necessary information in a designated section of the form because
of space limitations, please provide the information in the optional remarks section. The optional
remarks section will allow you to enter up to 500 characters. It is located near the end of the form
just above the signature line.
All required fields must be completed (with no blank lines between reported information).
Terms
Drop down field refers to a field containing the
symbol.
Definitions
Agent means any person who has been delegated the authority to obligate or act on behalf of a
provider.
Disclosing entity means a provider (other than an individual practitioner), or a fiscal agent.
Any entity that does not participate in Medicaid, but is required to disclose certain ownership and
control information because of participation in any of the programs established under title V,
XVIII, or XX of the Act means:
a. Any hospital, skilled nursing facility, home health agency, independent clinical
laboratory, renal disease facility, rural health clinic, or health maintenance organization
that participates in Medicare (title XVIII);
b. Any Medicare intermediary or carrier; and
c. Any entity (other than an individual practitioner or group of practitioners) that furnishes,
or arranges for the furnishing of, health-related services for which it claims payment
under any plan or program established under title V or title XX of the Act.
Fiscal agent means a contractor that processes or pays vendor claims.
Group of practitioners means two or more health care practitioners who practice their profession
at a common location (whether or not they share common facilities, common supporting staff, or
common equipment).
Indirect ownership interest means an ownership interest in an entity that has an ownership
interest in the disclosing entity. This term includes an ownership interest in any entity that has an
indirect ownership interest in the disclosing entity.
Individual practitioner means a physician or other person licensed or certified under State law to
practice his or her profession.
Managing employee means a general manager, business manager, administrator, director, or
other individual who exercises operational or managerial control over, or who directly or
indirectly conducts the day-to-day operation of an institution, organization, or agency.
Ownership interest means the possession of equity in the capital, the stock, or the profits of the
disclosing entity.
Person with an ownership or control interest means a person or corporation that--
a. Has an ownership interest totaling 5 percent or more in a disclosing entity;
b. Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;
c. Has a combination of direct and indirect ownership interests equal to 5 percent or more in
a disclosing entity;
d. Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other
obligation secured by the disclosing entity if that interest equals at least 5 percent of the
value of the property or assets of the disclosing entity;
e. an officer or director of a disclosing entity that is organized as a corporation; or
f. Is a partner in a disclosing entity that is organized as a partnership.
Significant business transaction means any business transaction or series of transactions that,
during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider's total
operating expenses.
Subcontractor means--
a. An individual, agency, or organization to which a disclosing entity has contracted or
delegated some of its management functions or responsibilities of providing medical care
to its patients; or
b. An individual, agency, or organization with which a fiscal agent has entered into a
contract, agreement, purchase order, or lease (or leases of real property) to obtain space,
supplies, equipment, or services provided under the agreement.
Supplier means an individual, agency, or organization from which a provider purchases goods
and services used in carrying out its responsibilities (e.g., a commercial laundry, a manufacturer
of hospital beds, or a pharmaceutical firm).
Wholly owned supplier means a supplier whose total ownership interest is held by a provider or
by a person, persons, or other entity with an ownership or control interest in a provider.
Doing Business As Field
The Doing Business As field is a required field. If you do not have a separate business name,
repeat the name of the entity/individual as it appears above.
Question 1
The drop down field to the right of the question is a required field. Indicate Yes or No by
choosing a value from the drop down box.
If your answer is Yes, provide the name of the person(s) and the description of the charge(s) in
the space provided. You will have a maximum of 100 characters in the description field to
provide your answer.
If your answer is No, leave the next section blank, and move to question #2.
Question 2
The drop down field to the right of the question is a required field. Indicate Yes or No by
choosing a value from the drop down box.
If your answer is Yes, provide the name, street, city, state and zip code. You can enter up to four
entries here. For each entry in question 2 (A,B,C etc.), you will need to provide at least one line
of information with a name, street, city, state and zip code in the second section. Designate the
correct name to associate with the line labeled A, B, C or D by choosing a value from the drop
down box. If line A (B,C etc.), requires two or more names be reported, choose the appropriate
letter as many times as necessary from the drop down field.
If your answer is No, leave the next section blank, and move to question #3.
Question 3
The drop down field to the right of the question is a required field. Indicate Yes or No by
choosing a value from the drop down box.
If your answer is Yes, provide the name, street, city, state and zip code and a description of the
business transaction. The field will accept up to 100 characters.
If your answer is No, leave the next section blank, and move to question #4.
Question 4
At least one line in the A,B,C section is required. You will need to provide the name, street, city,
state and zip code.
Questions 5 and 6 relate to the information you provide in this section.
Question 5
The drop down field to the right of the question is a required field. Indicate Yes or No by
choosing a value from the drop down box.
If your answer is Yes, indicate the line name (A, B, C, etc.) from question #4 by choosing a
value from the drop down box. Then state the name of the person that person is related to from
question 4, and indicate their relationship by choosing a value from the drop down box.
If your answer is No, leave the next section blank, and move to question #6.
Question 6
The drop down field to the right of the question is a required field. Indicate Yes or No by
choosing a value from the drop down box.
If your answer is Yes, indicate the line name (A, B, C, etc.) from question #4 by choosing a
value from the drop down box. Then state the name of the Medicaid provider or entity and
indicate the street, city, state and zip code.
If your answer is No, leave the next section blank, and move to the optional remarks section.
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