1-800-868-5200 (TRS 711)Mon., Tue., Thu., Fri.: 8 a.m. to 6 p.m. Wed: 10 a.m. to 6 p.m.
Federal law requires fiscal agents, managed care entities (MCEs), and other MassHealth providers, including applicants and certain bidders seeking to provide MassHealth services, to disclose some or all of the following: business ownership and control, business transactions, and criminal convictions. See 42 CFR §§ 455.100 – 106, 42 CFR 455.436, and 42 CFR §1002.3. MassHealth requires the submission of tax identification numbers (TINs), for example, social security number (SSN) or employer identification number (EIN), for purposes necessary to properly administer the MassHealth program (See 42 U.S.C. § 1320a-3 and 42 U.S.C. § 405 (c)(1).) Unless otherwise instructed by MassHealth, fiscal agents, MCEs, and other providers, must use this form when disclosing such information to MassHealth.
Disclosure form terms and definitions (pdf)
All applicants, bidders, disclosing entities, fiscal agents, and providers, including MCEs, must complete this section.
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.”
Identify any individuals or legal entities listed in question 1 as having an ownership or control interest, who also have an ownership or control interest in any other disclosing entity (or fiscal agent or MCE), and provide the name of each such other disclosing entity. If there are no individuals or legal entities with such interest, please respond “None.”
If there are no managing employees, please respond “None.”
Complete this section only if MassHealth directs you to do so. (Applicants and fiscal agents do not need to complete this section.)
1. Identify the ownership of any subcontractor with whom the provider, including an MCE, has had business transactions totaling more than $25,000 during the 12-month period before the date of this request. If there are multiple owners or shareholders, list only those with direct or indirect ownership of five percent or more. If there are no such business transactions to report, please respond “None.”
Applicants, bidders, and providers, including MCEs, must complete this section, unless otherwise directed by MassHealth.
Provide the requested information in this section for any person who
(1) (a) has an ownership or control interest in the disclosing applicant, bidder, MCE or provider, or
(b) is an agent or managing employee of the disclosing applicant, bidder, MCE or provider; and
(2) has also been convicted of a criminal offense related to any program under Medicare, Medicaid, or Title XX services since the inception of those programs.
If there are no persons with such interest, please respond “None.” Attach a separate sheet if more space is needed.
All bidders, applicants, providers, including MCEs, must complete this section, unless otherwise directed by MassHealth. For definitions and additional information to complete this section, see the Disclosure form terms and definitions.
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.)
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