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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Instructions for "Provider Disclosure Statement Form" - Delaware

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