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Group Provider Enrollment (Ownership) Page

You use the Ownership page to add or edit the group provider's ownership information to the enrollment application.

 

Ownership- Section 7 Fields

Field Description

Ownership Fields

1. List each office and/or individual, organization, corporation or entity that has direct or indirect ownership or controlling interest, separately or in combination, amounting to an ownership interest of 5% or more of the provider entity.

Enter those who have a 5% or more direct or indirect ownership interest in the group in the field provided.
To add new ownership information, click Add Ownership. Existing ownership information, if any, is listed in a table. To edit, in the Ownership table, click the appropriate table row. After changing or adding new ownership information, on the Ownership action bar, click Save.
Is the Owner an Individual or Group?

When adding an owner, select if the owner is an individual or group.

Depending on which answer you select, additional fields are displayed for you to enter individual or group ownership information. Field descriptions for both options are listed below.

Tip: This field is only displayed when you add ownership information. If you saved the information after choosing the wrong option, you must delete the incorrect entry in the table and add a new one."
Individual Selected As Owner Fields
Last Name Individual owner's last name.
First Name Individual owner's first name.
MI Individual owner's middle initial.
Position Individual owner's official title.
Address Individual owner's mailing address.
City Individual owner's city.
State Individual owner's state.
Zip Individual owner's zip code.
Doing Business (DBA) As Name Official name under which the individual owner is doing business.
Effective Date of Ownership

Date the ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select a date.
Date of Birth

Individual owner's date of birth.

Format: MM/DD/YYYY, or click the calendar to select a date.
State/Country of Birth State or country in which the individual owner was born.
SSN

Social Security number of the individual owner.

Format: ###-##-####
Percentage Percentage of individual ownership.
Alaska Medical Assistance Provider ID The individual's current Medicaid provider number.
Is this owner related to another owner as a spouse, parent, child, sibling, or household member?

Select Yes or No to indicate if the individual owner is related to another owner as a spouse, parent, child, sibling or household member.

If you select Yes, additional fields are displayed for you to complete for the relative.
Relationship The individual's relationship to the owner.
Group Selected As Owner Fields
Business Name Business name under which group ownership is held.
Doing Business As (DBA) Name Official name under which the organization is doing business.
FEIN The group's Federal Employer Identification number.
Address The group owner's mailing address.
City The group owner's city.
State The group owner's state.
Zip The group owner's zip code.
Percentage Percentage of group ownership.
Effective Date of Ownership

Date the ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select a date.
Alaska Medical Assistance Provider ID The group's current Medicaid provider number.

Relative/Household Member Fields

Is this owner related to another owner as a spouse, parent, child, sibling, or household member?

Select Yes or No to indicate if there are any persons with an ownership or controlling interest in your company related to one another.

If you select Yes, additional fields are displayed for you to complete.
To add new relatives, click Add Relative. Existing relatives, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding new ownership information, on the Relative action bar, click Save.
Last Name Last name of the relative or household member who holds the ownership and/or controlling interest.
First Name First name of the relative or household member who holds the ownership and/or controlling interest.
MI Middle initial of the relative or household member who holds the ownership and/or controlling interest.
Relationship The owner's relationship to the relative or household member who holds the ownership and/or controlling interest.

Managing/Directing Employees Fields

2. List all managing/directing employees for this Group.

Enter the number managing/directing employees for the group.

If you enter a number other than zero, additional fields are displayed for you to add or edit managing/directing employee information.
To add new managing/directing employee information, click Add Employee. Existing employees, if any, is listed in a table. To edit, in the Employee table, click the appropriate table row. After changing or adding employees, on the Employee action bar, click Save.
Last Name Last name of the managing/directing employee.
First Name First name of the managing/directing employee.
MI Middle initial of the managing/directing employee.
Position Title of the managing/directing employee.
Date of Birth

The date of birth of the managing/directing employee.

Format: MM/DD/YYYY, or click the calendar to select a date.
SSN

Social Security number of the managing/directing employee.

Format: ###-##-####
State/Country of Birth State or country in which the managing/directing employee was born.
Has the managing/directing employee ever had a Title XIX provider number in this or any other state?

Select Yes or No to indicate if the managing/directing employee has ever had a Medicaid provider number in this or any other state.

If you select Yes, additional fields are displayed for you to complete.
Doing Business As (DBA) Name Organization's legal business name as it appears in IRS forms.
FEIN The employee's or the organization's Federal Employer Identification number.
Current Alaska Medical Assistance Provider # The current Medicaid provider number.
State The State that issued the current Medicaid provider number.
Prior Alaska Medical Assistance Provider # The prior Medicaid provider number.
State The State that issued the prior Medicaid provider number.

Subcontractor Relative Fields

3. Do you have an ownership interest of 5% or greater in a subcontractor for your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/Provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients.)

Select Yes or No to indicate if you have any immediate family members who hold a 5% or greater ownership in a subcontractor to your business or practice.

If you select Yes, additional fields are displayed for you to complete.
To add a new subcontractor, click Add Subcontractor. Existing subcontractors, if any, are listed in a table. To edit, in the Subcontractor table, click the appropriate table row. After changing or adding new ownership information, on the Subcontractor action bar, click Save.
Subcontractor Name The subcontractor's name.
Address The subcontractor's address.
City The subcontractor's city.
State The subcontractor's state.
Zip The subcontractor's zip code.
FEIN The subcontractor's Federal Employer Identification Number.
Percentage The subcontractor's percentage of ownership.
To add new relatives, click Add Relative. Existing relatives, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding new ownership information, on the Relative action bar, click Save.
4. List members of your immediate family (spouse, parent, child, sibling) that have ownership of 5% or greater in a subcontractor to your business or practice.

Select Yes or No to indicate if you have any immediate family members who hold a 5% or greater ownership in a subcontractor to your business or practice.

If you select Yes, additional fields are displayed for you to complete.
Last Name Last name of the relative or household member who has ownership in the subcontractor business or practice.
First Name First name of the relative or household member who has ownership in the subcontractor business or practice.
MI Middle initial of the relative or household member who has ownership in the subcontractor business or practice.
Relationship Relationship of relative or household member to the owner of the subcontractor business or practice (spouse, parent, sibling, etc.)
Subcontractor Name Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients that is associated with the relative.
Address Physical street address of the subcontractor associated with the relative.
City City where the subcontractor associated with the relative is located.
State State where the subcontractor associated with the relative is located.
Zip Zip code and extension where the subcontractor associated with the relative is located.
FEIN Federal Employer Identification Number of the subcontractor associated with the relative.
Percentage The relative or household member's percentage of ownership.

 

Version as of 6/30/2015.

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