A. Identification Information
All applicants, bidders, disclosing entities, fiscal agents, and providers, including MCEs, must complete this section.
B: Ownership and Control
All applicants, bidders, disclosing entities, fiscal agents, and providers, including MCEs, must complete this section, unless otherwise directed by MassHealth.
(1) List the name and address of any person (individual or legal entity) with an ownership or control interest in the entity providing these disclosures, or with an ownership or control interest in any subcontractor in which the disclosing entity has a direct or indirect ownership of five percent or more. Provide the date of birth and SSN (for individuals identified), or other TIN (for legal entities identified), and complete the additional requested information. If there is no person or entity in this category, please respond “None.”
F. Provider/Fiscal Agent/MCE/Applicant, Bidder Attestation, Signature, and Date
All providers, fiscal agents, MCEs, and applicants must complete this section.
I certify that the information on this form, and any attached statement that I have provided, has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I understand that I sign under the pains and penalties of perjury, and may be subject to civil penalties or criminal prosecution for any falsification, omission, or concealment of any material fact contained herein.
Provider’s/disclosing entity’s/fiscal agent’s/MCE’s/applicant’s/bidder’s signature (signature and date stamps, or the signature of anyone other than the provider/fiscal agent, applicant, bidder, or in the case of a legal entity, person legally authorized to sign on behalf of the entity are not acceptable.)