IMPORTANT FACTS TO REMEMBER Submission of an application does not constitute automatic acceptance or re-enrollment into the program.

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1 Government of the District of Columbia Department of Health Care Finance (DHCF) Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DME/POS) Medicaid Provider Enrollment Package APPLICATION PROCESS Step One New applicants and re-enrolling providers are required to first submit a completed application along with requested documentation. A separate application is required for each service location at which the applicant intends to provide DME/POS services. DHCF will review the application and make a determination within 30 business days as to whether the applicant can proceed to the next steps of the application process. Applicants not successfully completing Step One will be notified in writing. Completion of Step One, by itself, does not constitute acceptance into the Program. Step Two Applicants successfully completing Step One will be required to attend a mandatory provider orientation (specific staff from the applying company must attend, as appropriate) and sign a Provider Agreement along with accompanying documents. Step Three Applicants successfully completing Steps One and Two of the process will be notified of their acceptance or re-enrollment into the Program. Once notified of acceptance, providers will be permitted to bill and receive reimbursement for services rendered to District of Columbia Medicaid recipients. IMPORTANT FACTS TO REMEMBER Submission of an application does not constitute automatic acceptance or re-enrollment into the program. Anticipated time for DHCF s review of applications and determination of whether applicants can proceed to orientation is approximately 30 business days. Applications will be rejected and returned to sender if any information is omitted, requested documentation is not included, or the submitted package is not assembled as instructed. A National Provider Identifier (NPI) is mandatory. For information on the NPI, visit In-State DME/POS Providers are defined as entities whose service site is located inside the geographic boundaries of the District of Columbia. Out of-state DME/POS Providers are defined as entities whose service site is located outside the geographic boundaries of the District of Columbia. A separate application is required for each location at which the applicant intends to provide DME/POS services. Complete each section of the application, if applicable. Do not remove any pages from the application package. Electronic copies of the DME/POS Provider Enrollment Package can be found on the District of Columbia Department of Health Care Finance website at Last Revised 4/15/09 1

2 Direct questions to: District of Columbia Fiscal Agent Affiliated Computer Services, Inc. (ACS) Enrollment Division 8 A.M. to 5 P.M. EST, Monday through Friday (inside the District of Columbia) (outside the District of Columbia) Mail completed application package to: Provider Enrollment Affiliated Computer Services, Inc. (ACS) Provider Enrollment P.O. Box Washington, DC Last Revised 4/15/09 2

3 GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Care Finance (DHCF) DURABLE MEDICAL EQUIPMENT, PROSTHETIC, ORTHOTICS AND MEDICAL SUPPLIES (DME/POS) PROVIDER APPLICATION PACKAGE Important: Read all instructions before completing the application. Type or print clearly, in ink. If you make corrections, please line through, date, and initial in ink. Return the completed application package and accompanying documentation in the format specified to: ACS Provider Enrollment P.O. Box Washington, DC DISTRICT OF COLUMBIA DME/POS MEDICAID PROVIDER APPLICATION FOR (Insert the full legal name of your company) Section 1 ENROLLMENT ACTION Washington, DC Directions: Do not Check use staples ( ) ALL on that this apply. application or on any attachments. Do not leave any questions, boxes or lines blank. Enter N/A if not applicable. A National Provider Identifier (NPI) is mandatory for all new applicants and re-enrolling providers. A Medicare Provider Number is required for all applicants. If re-enrolling as a Medicaid provider, provide your DC Medicaid provider number. If changing/ updating information, indicate the type of change requested and the effective date of the change. ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE (if applicable): o Copy of your NPI letter o CMS Medicare Supplier letter New provider National Provider Identifier (NPI): Medicare Provider Number: For any of the following actions, include current or previous D.C. Medicaid provider number: Re-Enrollment (required every three (3) years) Change/Update (state the type of change/update and the effective date below). Last Revised 4/15/09 3

4 The National Provider Identifier (NPI) final rule, Federal Register 45CFR Part 162, was published on January 23, 2004 by the Department of Health and Human Services (DHHS) as part of the Health Insurance Portability and Accountability Act (HIPAA). The rule established the NPI as the standard unique identifier for health care providers to be used in HIPAA-covered transactions. The rule requires covered health care providers, clearinghouses, and health plans to use this identifier in HIPAA-covered transactions. All DC Medicaid healthcare providers must provide DHCF with their NPI information. Please complete the below information and return with your Medicaid Provider Enrollment Application. If you do not have an NPI yet, you may obtain one at If you do not meet the definition of healthcare provider as defined under HIPAA, this form is not required. If you are a healthcare provider please provide your NPI that was issued by National Plan & Provider Enumeration System (NPPES) in the space below. Please also provide your taxonomy code that is currently on file with NPPES. NPI Taxonomy Code X If this application is for an organization, please supply additional NPIs and taxonomy codes on a separate sheet. I certify this information to be true and accurate. Provider Signature or Authorized Representative Printed Name Date Last Revised 4/15/09 4

5 Section 2 BUSINESS/CORPORATE Directions: Check one box only. If Other is checked, write in type of entity. ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE: o Business License o Certificate of Occupancy o Applicable Permits o Legible copy of the partnership agreement (if Partnership is checked) TYPE OF ENTITY (check one) Sole proprietor Partnership (attach legible copy of agreement) Government Entity Corporation: Limited Liability Company (LLC): Nonprofit Corporation Other: State Registered/Filed: Last Revised 4/15/09 5

6 Section 3 APPLICANT/PROVIDER Directions: 3a) Company Name o Provide company name or corporate name as registered with the Internal Revenue Service (IRS) and under which business is conducted. o Provide primary business location address, telephone and fax numbers, website and address. 3b) Out-of-State Applicants ONLY o Providers located outside the District of Columbia must have a registered agent, be enrolled as a Medicaid provider in state where your business is principally located, and be registered in the District of Columbia to conduct business. o Provide information regarding your District of Columbia registered agent. o PO Boxes are prohibited ATTACH THE FOLLOWING DOCUMENTS BEHIND THIS PAGE (if applicable): o D.C. Certificate of Authority [Corporation] or D.C. Certificate of Registration [LLC] (Out-of-State providers ONLY) o Proof of Medicaid enrollment in your state (Out-of-State providers ONLY) o Description of ownership and a list of major owners (stockholders owning or controlling five (5) percent or more outstanding shares) o List of Board Members and their affiliations o Copy of the basic organizational documents of the provider, a roster of key personnel with titles, including an organizational chart 3a) Company Name, as listed with the IRS. (Note: Name indentified below should match name indentified on the IRS form included in this application package.) Name of Owner(s) Doing Business as Business Address City/State/Zip Telephone Fax Website 3b) Out-of-State applications ONLY 1. Registered Agent (PO Box Prohibited): Name (Last, First, Middle) Company Name Address City/State/Zip Telephone Website 2. Medicaid Provider Number in the state where your business is principally located (Attach copy proof of Medicaid enrollment in your State) Last Revised 4/15/09 6

7 Section 4 PROOF OF LIABILITY INSURANCE Directions: Minimum coverage is $300,000. ATTACH THE FOLLOWING DOCUMENT BEHIND THIS PAGE: o Copy of the Certificate of Insurance for the business address listed on this application Name of Insurance Company Insurance Policy Number Date Policy issued (mm/dd/yyyy) Expiration Date of Policy (mm/dd/yyyy) Insurance Agent s Name (Last, First, MI) Telephone Number ( ) Fax Number ( ) Address Last Revised 4/15/09 7

8 Section 5 BACKGROUND CHECKS Directions: In 5a, state whether or not any personnel providing services at this service site do now or will: 1) enter beneficiaries homes to deliver DME/POS products, to fit DME/POS products to patients, or for other purposes; or 2) have physical contact with beneficiaries to ensure the correct fit or teach appropriate use of prosthetics, wheelchairs, or other DME/POS equipment; or have any other physical contact with patients beyond that physical contact routinely made by a cashier or other personnel performing administrative activities. In 5b, list every person in your company at this service location who will have contact with DC Medicaid recipients in any of the ways described above. For each such person: o If he or she holds a current professional license as a health care provider, attach a copy of the license. o If he or she does not currently possess a valid license as a health care provider, provide evidence of a background check. If additional space is needed, attach separate sheet(s) of paper behind the next page. FOR EVERY PERSON LISTED IN 5b, ATTACH THE FOLLOWING DOCUMENTS BEHIND 5b: o Copies of the professional license(s) of all personnel who are licensed as a health care provider and who have or will have physical contact with beneficiaries (as described above); and o Copies of current (within the past 90 days) criminal background checks for each person who has or will have physical contact with beneficiaries as described above, and who does not currently have a valid professional license as a health care provider. 5a) Declaration of whether personnel have physical contact with beneficiaries. Please answer YES or NO to the following questions: Do (or will) any personnel providing services at this service site: 1) enter beneficiaries homes to deliver DME/POS products, to fit DME/POS products to patients, or for other purposes? YES NO 2) have physical contact with beneficiaries to ensure the correct fit or teach appropriate use of prosthetics, wheelchairs, or other DME/POS equipment; or have any other physical contact with patients beyond that physical contact routinely made by a cashier or other personnel performing administrative activities. YES NO If you answered YES to either of the above two questions, go to 5b. 5b) List of personnel with physical contact with beneficiaries. On the next page(s), list every person in your company at this service location who will have contact with DC Medicaid recipients in any of the ways described above. For each such person: o If he or she holds a current professional license as a health care provider, provide a copy of the license. o If he or she does not currently possess a valid license as a health care provider, provide evidence of a background check. State the number of copies of professional licenses that are included here: State the number of criminal background checks that are included here: Last Revised 4/15/09 8

9 5b, continued: Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Name Indicate whether a professional license or background check is being provided (check one): Background check Professional License Last Revised 4/15/09 9

10 THIS PAGE INSERTED AS A REMINDER TO INSERT HERE ALL BACKGROUND CHECKS AND COPIES OF PROFESSIONAL LICENSES FOR EVERY INDIVIDUAL LISTED IN 5b Last Revised 4/15/09 10

11 Section 6 SERVICE LOCATION AND HOURS OF OPERATION Directions: Provide the information below for the service location you intend to enroll or re-enroll in DC Medicaid. Post Office Boxes are prohibited 6a) Service Location Address City/State Zip Code Telephone Number Fax Number WARD/COUNTY Address 6b) Hours of Operation Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6c) Does this location have 24-hour 6d) Is this location accessible to public 6e) Does this location meet the access Telephone coverage? Yes No Transportation? Yes No requirements of the Americans with Disabilities Act? Phone: ( ) Yes No 6f) Does the location have TDD? Yes No TDD Telephone Number Section 7 MAILING ADDRESS FOR PAYMENT OR REMITTANCES Directions: o Provide the address to which you want payments sent. A Post Office Box is acceptable. o Provide the address to which you want Remittance Advices sent. A Post Office Box is acceptable. o Only one Remittance Address is allowed per provider number. Check whether you will use electronic or paper billing. 7a) Address to which payment should be sent: Address City/State ZIP Code 7b) Address to which Remittances should be sent: Address City/State ZIP Code (if difference from Pay to Address) 7c) How are you billing? Electronic Paper Last Revised 4/15/09 11

12 Section 8 MAILING ADDRESS FOR CORRESPONDENCE OTHER THAN PAYMENT OR REMITTANCES Directions: Provide the mailing address to which correspondence (manual updates, memoranda, etc.) should be sent. A Post Office Box address is acceptable. Only one Correspondence Address is allowed per enrollment application and provider number. Address to which correspondence should be sent: Address City/State ZIP Code Last Revised 4/15/09 12

13 Section 9 PRODUCTS AND SERVICES TO BE FURNISHED BY PROVIDER Directions: Complete the chart by placing a check ( ) in the box next to the specific products (listed in Column I) that your business will deliver to DC Medicaid recipients. In Column II, check the specific licensure and/or certification held by those persons who will deliver the products and services. If a specific licensure and/or certification that you hold is not listed below, write or type the name of the licensure, certification or other credential in the space provided in Column II for Other. If a product that you intend to deliver is not listed in the chart below, write or type the name of the product in the space provided at the end of Column I. COLUMN I PRODUCTS TO BE FURNISHED BY PROVIDER Diabetic Footwear Orthotics Devices Custom-Fabricated COLUMN II QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS Fitters of therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts) ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic Fitter (COF) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Orthotic Devices (Custom-Fabricated) ABC Certified Practitioner (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) ABC Registered Orthotic Technician (RTO) for individuals who under the direct supervision of an ABC certified practitioner administers orthotic services and products. (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic (BOCO) (Board for Orthotic/Prosthetic Certification) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Fitters of orthotics, products and services; or therapeutic shoes (non-custom therapeutic shoes and diabetic multi-density inserts) ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic Fitter (COF) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Pedorthic Devices Therapeutic Shoes - Customized Shoe Modifications Foot Orthoses Pedorthic devices (therapeutic shoes, shoe modifications, & foot orthoses) ABC Certified Pedorthist (C.Ped) (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC Pedorthist Certification (Board for Orthotic/Prosthetic Certification) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Last Revised 4/15/09 13

14 PRODUCTS TO BE FURNISHED BY PROVIDER (Continued) Power Wheelchairs Prosthetics General * (i.e. non-customized therapeutic shoes) Specialty (i.e. Speech Generating Devices, Voice Prosthetics Mastectomy QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS (Continued) Customized Manual Wheelchairs and Complex Rehabilitative Wheelchairs & Assistive Technology RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Rehabilitation Engineering Technologist (RET) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Assistive Technology Supplier (ATS) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with an Assistive Technology Practitioner (ATP) credential Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Prosthetic Devices ABC Certified Practitioner (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) ABC Registered Prosthetic Technician (RTP) for individuals who under the direct supervision of an ABC certified practitioner administers orthotic/prosthetic service and products. (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Prosthetic (BOCP) (Board for Orthotic/Prosthetic Certification) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s) Specify Fitters of mastectomy prostheses, products and services; or therapeutic shoes (non-custom therapeutic shoes and diabetic multidensity inserts) ABC Certified Fitter credential (American Board for Certification in Orthotics, Prosthetics and Pedorthics, Inc.) BOC-Certified Orthotic Fitter (COF) and/or BOC-Certified Mastectomy Fitter (CMF) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s): Specify Respiratory Equipment Bi-level Positive Airway Pressure Continuous Positive Airway Pressure Intermittent Positive Pressure Respiratory Assist Devices Wheelchairs Manual (Customized) Respiratory Equipment, Supplies, and Services Registered Respiratory Therapist (RRT) Certified Respiratory Therapist (CRT) Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s): Specify Customized Manual Wheelchairs, Power Mobility Devices and Complex Rehabilitative Wheelchairs & Assistive Technology RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Rehabilitation Engineering Technologist (RET) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with a Assistive Technology Supplier (ATS) credential RESNA Certified Rehabilitative Technology Supplier (CRTS), with an Assistive Technology Practitioner (ATP) credential Other certification by an independent body (i.e., a body that does not receive profit from the sale or distribution of the product(s): Specify Last Revised 4/15/09 14

15 PRODUCTS TO BE FURNISHED BY PROVIDER (Continued) Additional DME/POS Apnea Monitor Commodes Diabetic Equipment and Supplies Blood Glucose Monitors QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS (Continued) Applicable licensure, certification and/or training. NOTE: Products in this section only may not require specific licensure, certification or training Dialysis Equipment and Supplies Heat/Cold Applications Hemodialysis Equipment and Supplies Hospital Beds Accessories Electric Manual Lymphoedema Pumps Mobile Assistive Equipment Walkers, Canes and Crutches Patient Lifts and Seat Lift Mechanisms Orthotics Devices Non-customized Oxygen Oxygen equipment Concentrators Reservoirs High-pressure cylinders Accessories & Supplies Conserving Devices Wound Care Supplies Last Revised 4/15/09 15

16 PRODUCTS TO BE FURNISHED BY PROVIDER (Continued) Other DME/POS Applicable licensure, certification and/or training. QUALIFICATIONS TO PROVIDE SPECIFIC PRODUCTS (Continued) Last Revised 4/15/09 16

17 Section 10 QUALIFICATIONS OF THE DME/POS BUSINESS Directions: Check [ ] agencies where any accreditation is held by your DME/POS business. ATTACH PROOF OF ACCREDITATION BEHIND THIS PAGE. The Joint Commission (JC) National Association of Boards of Pharmacy (NABP) Board of Orthotist/Prosthetist Certification (BOC) Community Health Accreditation Program (CHAP) The Compliance Team, Inc. American Board of Certification in Orthotics & Prosthetics, Inc. (ABC) The National Board of Accreditation for Orthotic Suppliers (NBAOS) Commission on Accreditation of Rehabilitation Facilities (CARF) HealthCare Quality Association on Accreditation (HAQAA) Accreditation Commission for Health Care, Inc. (ACHC) Last Revised 12/11/08 17

18 Section 11 BUSINESS INFORMATION Directions: 11a) -11i) Check Yes or No in response to the questions listed. 11j) If Yes is checked for #2, provide the name and telephone number of the person who holds ownership of the warehouse, along with the owner s complete address. 11k 11o) Check Yes or No in response to the questions listed. 11p 11r) Check Yes or No in response to the questions listed. If Yes is checked, please explain in the space provided in Section s) Check Yes or No in response to the questions listed. If Yes is checked provide the information requested in the space provided in Section a) Do you have the retail business open and available to the general public, and which meets all local laws and ordinances regarding business licensing and operations and is readily identifiable as a place in which you sell, rent, or lease durable medical equipment, prosthetics, incontinence medical supplies, and/or medical supply items? Yes No 11b) Do you have a visible sign and posted hours of operation? Yes No 11c) Do you have inventory or contracts with other companies to ensure the ability to fill orders? Yes No 11d) Do you advise customers that they may either rent or purchase DME/POS? Yes No 11e) Do you honor all warranties expressed and implied under State law? Yes No 11f) Do you have a written complaint resolution process? Yes No 11g) Will records be stored at the service location? Records must be maintained for 10 years If not, where are they stored? Provide Address: Address: City/State Zip Code Yes No 11h) Do you own the building in which your business is located? Yes No 11i) Do you lease the building in which your business is located? Yes No 11j) Is your equipment and/or supplies: #1) In stock on the premise, and/or #2) In a warehouse under the applicant s or provider s direct control (if checked provide the following information for the warehouse): Yes Yes No No Name of Person who holds ownership in the warehouse: Address: City/State Zip Code Telephone Number: 11k) Do you have the necessary equipment, office supplies, and facilities available to carry out your business, including storing and retrieving such records as are necessary to fully disclose the type and extent of services provided to Medicaid customers? 11l) Does you business involve the trade, sale, rental, or transfer of upholstered - furniture (including wheelchairs) or bedding? 11m) Does your business involve the trade, sale, rental or transfer of medical devices or durable medical equipment/devices for use in the home to treat acute or chronic illness of injuries? 11n) Does your business involve the trade, sale, rental or transfer of dangerous or legend drugs and/or dangerous or legend medical equipment devices? 11o) Does the applicant/provider provide custom rehabilitative equipment and custom rehabilitative technology services to Medicaid customers? Yes Yes Yes Yes Yes No No No No No Last Revised 12/11/08 18

19 If Yes, does the applicant/provider have on staff, either as an employee or independent contractor, or does the applicant/provider have a contractual relationship with a qualified rehabilitation professional who was directly involved in determining the specific custom rehabilitation equipment needs of the patient and was directly involved with, or closely, supervised, the final fitting and delivery of the custom rehabilitation equipment? 11p) Has any officer and/or employee of the business ever been convicted of a felony? Yes No Yes No If Yes, please explain in Section 12 11q) Has the applicant/provider ever been rejected or suspended from the Medicare or Medicaid program, or has your participation status ever been modified (terminated, suspended, restricted, revoked, limited, cancelled or sanctioned)? 11r) Within the last five (5) years, has the applicant/provider ever been sanctioned, reprimanded or otherwise disciplined in any manner by any state licensing authority or other professional board or peer committee? 11s) Does applicant/provider own, have an investment in, manage, own stock in, participate in a joint venture, or act as a partner, contract consultant or medical/dental advisor in any medical/dental enterprise or medical/dental supplier outside of the business identified in this application where you would financially benefit directly or indirectly? Yes No If Yes, please explain in Section 12 Yes No If Yes, please explain in Section 12 Yes No If Yes, please explain in Section 12 Last Revised 12/11/08 19

20 Section 12 DETAILED EXPLANATIONS FOR SECTION 10 QUESTIONS Directions: If you answered YES to questions 11p, 11q, 11r and 11s, please provider an explanation or additional information for each. QUESTION 11p QUESTION 11q QUESTION 11r QUESTION 11s Name of Organization Type of Organization Mailing Address Telephone Number Tax ID Number Percent of Business Owned/Invested by You Nature of Business Investment (Owner, Partner, Investor, etc.) Last Revised 12/11/08 20

21 Section 13 DISCLOSURE OF OWNERSHIP Directions: Follow the instructions found in this section to complete the document on the next page. Remember to sign the document. INSTRUCTION FOR COMPLETING DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (DC-1513) Completion and submission of this form is a condition of participation, certification, or recertification under any of the programs established by Titles V, XVIII, XIX, AND XX, or as a condition of approval or renewal of a contractor agreement between the disclosing entity and the District of Columbia state agency under any of the above-titled programs, a full and accurate disclosure of ownership and financial interest is required. Failure to submit requested information may result in a refusal by the D.C. State Agency to enter into an agreement or contract with any such institution or in termination of existing agreements. SPECIAL INSTRUCTIONS FOR TITLE XX PROVIDERS All title XX providers must complete Part II (a) and (b) of this form. Only those Title XX providers rendering medical, remedial, or health related homemaker services must complete Parts II and III. Title V providers must complete Parts II and III. General Instructions For definitions, procedures and requirements refer to the appropriate Regulations: Title V -42CFR 51a.144 Title XVIII -42CFR Title XIX -42CFR Title XX -45CFR Please answer all questions as of the current date. If the yes block for any item is checked, list requested additional information under the Remarks Section on page 2, referencing the item number to be continued. If additional space is needed use an attached sheet. Return the original copy to the State agency: retain the photocopy for your files. DETAILED INSTRUCTIONS These instructions are designed to clarify certain questions on the from. Instructions are listed in question order for easy reference. No instructions have been given for questions considered self-explanatory. IT IS ESSENTIAL THAT ALL APPLICABLE QUESTIONS BE ANSWERED ACCURATELY AND THAT ALL INFORMATION BE CURRENT. Item I Under identifying information specify in what capacity the entity is doing business as (DBA), example, name of trade or corporation. Item II- Self-explanatory Item III- List the names of all individuals and organizations having direct or indirect ownership interests, or controlling interest separately or in combination amounting to an ownership interest of 5 percent or more in the disclosing entity. Direct ownership interest is defined as the possession of stock, equity in capital or any interest in the profits of the disclosing entity. A disclosing entity is defined as a Medicare provider or supplier, or other entity that furnishes services or arranges for furnishing services under Medicaid or the Maternal and Child Health program, or health related services under the social services program. Indirect ownership interest is defined, as ownership interest in an entity that has direct or indirect ownership interest in the disclosing entity.the amount of indirect ownership in the disclosing entity that is held by any other entity is determined by multiplying the percentage of ownership interest at each level. An indirect ownership interest must be reported if it equates to an ownership interest of 5 percent or more in the disclosing entity. Example: if A owns 10 percent of the stock in a corporation that owns 80 percent of the stock of the disclosing entity, A s interest equates to an 8 percent indirect ownership and must be reported. Controlling interest is defined as the operational direction or management of a disclosing entity, which may be maintained, by any or all of the following devices: the ability or authority, expressed or reserved, to amend or change the corporate identity (i.e. joint venture agreement, unincorporated business status) of the disclosing entity; the ability or authority to nominate or name members of the Board of Directors or Trustees of the disclosing entity; the ability or authority, expressed or reserved, to amend or change the by-laws, constitution, or other operating or management direction of the disclosing entity; the right to control any or all of the assets or other property of the disclosing entity upon the sale or dissolution of that entity; the ability or authority, expressed or reserved, to control the sale of any or all of the assets, to encumber such assets by way of mortgage or other indebtedness, to dissolve the entity, or to arrange for the sale or transfer of the disclosing entity to new ownership or control. Items IV-VII- Changes in Provider Status Change in provider status is defined as any change in management control. Examples of such changes would include: a change in Medical or Nursing Director, a new Administrator, contracting the operation of the facility to a management corporation, a change in the composition of the ownership partnership which under applicable State law is not considered a change in ownership, or the hiring or dismissing of any employees with 5 percent or more financial interest in the facility or in an owning corporation or any change of ownership. For Items IV-VII, if the yes box is checked, list additional information requested under Remarks. Clearly identify which item is being continued. Item IV- (a & b) If there has been a change in ownership within the last year or if you anticipate a change, indicate that date in the appropriate space. Item V- If the answer is yes, list name of the management firm and employer identification number (EIN), or the name of the leasing organization. A management company is defined as any organization that operates and manages a business on behalf of the owner of that business, with the owner retaining ultimate legal responsibility for operation of the facility. Item VI- If the answer is yes, identify which has changed (Administrator, Medical Director, or Director of Nursing) and the date the change was made. Be sure to include name of the new Administrator, Director of Nursing or Medical Director, as appropriate. Item VII- A chain affiliate is any free-standing health care facility that is either owned, controlled, or operated under lease or contract by an organization consisting of two or more free-standing health care facilities organized within or across State lines which is under the ownership or through any other device, control and direction of a common party. Chain affiliates include such facilities whether public, private, charitable or proprietary. They also include subsidiary organizations and holding corporations. Provider-based facilities, such as hospital-based home health agencies, are not considered to be chain affiliates. Item VIII -If yes, list the actual number of beds in the facility now and the previous number Last Revised 12/11/08 21

22 DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT Identifying Information (a). Name of Entity D/B/A Medicaid Provider No. NPI Number. Telephone No. Street Address City, County, State Zip Code II. Answer the following questions by checking Yes or No. If any of the questions are answered Yes, list names and addresses of individuals or corporations under Remarks on page 2. Identify each item number to be continued. A. Are there any individuals or organizations having a direct or indirect ownership or control interest of 5 percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons, or organizations in any of the programs established by Titles XVII, XIX, or XX? Yes No B. Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a criminal offense related to their involvement in such programs established by Titles XVII, XIX, or XX? Yes No C. Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution s organization s, or agency s fiscal intermediary or carrier within the previous 12 months? (Title XVII providers only) Yes No III. (a.) List names, addresses for individuals, or the EIN for organization having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under Remarks on Page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks. Name Address EIN (b) Type of Entity: Sole Proprietorship Partnership Corporation Unincorporated Associations Other (Specify) (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks. Check appropriate box for each of the following questions (d) Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example, sole proprietor, partnership or members of Board of Directors.) If yes, list names, addresses of individuals and provider numbers. Yes No Name Address Provider Number Last Revised 12/11/08 22

23 IV. (a). Has there been a change in ownership or control within the last year? If yes, give date Yes No (b) Do you anticipate any change of ownership or control within the year? If yes, when? Yes No (c) Do you anticipate filing for bankruptcy within the year? If yes, when Yes No (d)is this facility operated by a management company, or leased in whole or part by another organization? Yes If yes, give date of change in operations No V. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN) Yes No Name EIN# Address WHOEVER KNOWINGLY AND WILLFULLY MAKES OR CAUSES TO BE MADE A FALSE STATEMENT OR REPRESENTATION OF THIS STATEMENT, MAY BE PROSECUTED UNDER APPLICABLE FEDERAL OR STATE LAWS. IN ADDITION, KNOWINGLY AND WILLFULY FAILING TO FULLY AND ACCURATELY DISCLOSE THE INFORMATION REQUESTED MAY RESULT IN DENIAL OF A REQUEST TO PARTICIPATE OR WHERE THE ENTITY ALREADY PARTICIPATES, A TERMINATION OF ITS AGREEMENT OR CONTRACT WITH THE D. C. STATE AGENCY AS APPROPRIATE. Name of Authorized Representative Title Signature Date Last Revised 12/11/08 23

24 Section 14 REQUEST FOR TAXPAYER IDENTIFICATION NUMBER AND CERTIFICATION Directions: Complete the document on the next page. Remember to sign the document. Last Revised 12/11/08 24

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27 Section 15 AUTHORIZATION TO RELEASE INFORMATION Directions: Review this document carefully. Sign and date it. I authorize the District of Columbia Medical Assistance Administration, hereafter agency and its affiliates, subsidiaries or related entities to consult with hospital administrators, members of medical staffs of hospitals, malpractice carriers, licensing boards, professional organizations, and other persons to obtain and verify information and I release to the agency and its employees and agents from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application; and, I consent to the release by any person to the agency of all information that may be reasonably relevant to an evaluation of my professional competency, character, and moral and ethical qualification, including any information relating to any disciplinary action, suspension or limitation of privileges, and hereby release any such person providing such information from any and all liability for doing so. This credentialing information and the attached documents contain detailed and specific information relating to my character and professional competence. I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief. I understand that willful falsification or willful omission of this information will be grounds for rejection or termination. I further agree to notify the agency of any change to the information provided in this application within thirty (30) days of any such change. I understand that any information provided in this application that is not publicly available will be treated as confidential by the carrier. Signature of Authorized Applicant/Provider Printed Name of Authorized Applicant/Provider Date Telephone Number Contact person to answer questions regarding application Telephone Number Last Revised 12/11/08 27