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Georgia Home Health Agency Medicaid Facility Enrollment Application

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Georgia Home Health Agency Medicaid Facility Enrollment Application Powered By Docstoc
					                                                             Georgia Department of Community Health
                                                                  Facility Enrollment Application

  Dear Applicant,
  Thank you for your interest in enrolling as a Georgia Medicaid provider. In order for us to complete the enrollment process, please
  mail the following documents to Hewlett-Packard Enterprise Services (HPES) at one of the addresses listed at the end of the
  instructions.
  Please refer to http://www.mmis.georgia.gov/portal/PubAccess.Enrollment/tabId/63/Default.aspx for the appropriate Contract cover
  sheet listing all required supporting documentation.
  Retain a copy of your completed Provider Enrollment Application packet and all documentation submitted for your records. You will
  be notified by mail at the Correspondence Address provided on this application if additional information is needed and/or the
  enrollment process has been completed. Billing information and clinical coverage polices are available on the HPES’s website at
  http://www.mmis.georgia.gov.
  Thank you again for your interest. If you have any questions or need additional information, please refer to the enrollment information
  available at http://www.mmis.georgia.gov or contact HPES Provider Enrollment at 1-800-766-4456.
  Special Instructions - Please read thoroughly before completing this application. It is recommended that a pen with black or
  blue ink be used and print legibly. Applications that are copies or faxes, incomplete, or unreadable will not be accepted or
  processed.
  A. Applicant Base Information:
  National Practitioner Identifier number (NPI) is REQUIRED for ALL Applicants. If you do not have an NPI number, please go to
  https://nppes.cms.hhs.gov/NPPES/Welcome.do and request one. Enter the Legal Business Name, Doing Business As (if applicable), Type of Facility, and State where
  your practice is incorporated. Additionally, complete the section below it in regards to the additional sites. Attach details if additional space is needed. .
  Facility Type Valid Values:
                       0 Government                              1 Non-Profit or Religious                            2 Sole Proprietorship
                       3 Investor-Owned                          4 Public                                             5 Private – For Profit
                       6 Private – Not for Profit                7 Not Applicable                                     9 Other
  B. Address Information:
  1. The Service Location (Physical) Address is required for all providers. This is the street address from where you intend to provide services to Medicaid and/or
     PeachCare for Kids members. Post office boxes are not allowed. All fields marked with “*” are required, including ZIP + 4.
  2. Payee Designation: Enter the Legal Business Name, Georgia Medicaid Payee ID (if known), and Tax ID numbers associated with the practice the applicant will be
     rendering services for. This Payee ID can be found on the top right corner of the existing Payee’s Remittance Advice. If a Payee number has NOT been established,
     please write the Legal Business name (as shown on your IRS tax documentation) and Tax ID Number in the appropriate field. Tax ID number must be on the
     application or it will be returned. You may leave the Payee ID field blank. Form W-9, EFT Agreement, and IRS Tax ID verification (147-C, CP575-A, etc. available
     from the IRS) are required supporting documents and a new Payee ID will be created as part of the enrollment process.
  3. The Correspondence Address is optional. Use this field if you would prefer to receive postal mail at an address other than the address provided above. All
     correspondence regarding this application will be sent to this address including letters of deficiency as well as the notification of approval. Post office boxes are
     allowed. If this information is the same as the physical location address listed above, please indicate by marking the “N/A” checkbox.
  4. Enrollment Application Contact Information. Please remember that ALL correspondence in regards to this application will be sent using postal mail to the
     Correspondence Address provided on the application in step 3 above.
  C. Program Enrollment Information
  Use this section to indicate which Provider Type (only ONE) and Contract(s) (formerly known as Category of Service) you are applying to enroll in.
                                                                  Provider Type Code valid values:
  10Behavioral Health & Social Ser                        26 Ambulatory                           38 Home and Community Based Services
  14Emergency Medical Service Provider                    28 Hospital                             170 Other Service Providers
  16Nursing Services                                      29 Laboratories                         251 Public Health Agencies
  22Respiratory, Rehab, & Restoration                     31 Nursing Facilities
  25Agencies                                              33 Medical Supplier
  Contract Code valid values: ** These Contract (440, 680, 681) Applications need to be submitted DIRECTLY to DBHDD and Contract (590) Applications
                                       need to be submitted to DHS Department of Aging Services, not HP Provider Enrollment.**
010/070 – Inpatient/Outpatient Hospital Services        371 – Emergency Air Ambulance Services                    681 – Community Habilitation & Support Services Waiver**
080 – Swing-bed Services                                440 – Community Mental Health Services**                  690 – Hospice
100– Dedicated Case Management Services                 540 – Federally Qualified Health Centers                  720 – Dialysis – Technical
110, 140-180 – Nursing Facility Services                541 – Hospital-Based Rural Health Services                730-Pregnancy Related Services
200 – Home Health Services                              542 – Free-Standing Rural Health Clinic                   761-Perinatal Case Management
230 – Independent Laboratory Services                   590 – Community Care Services**                           790 – Diagnostic, Screening and Preventive Services
270 – Family Planning Clinic Services                   600 – Health Check Services                               800 – Early Intervention Case Management Services
320 – Durable Medical Equipment                         660 – Independent Care Waiver Services                    971-GAPP
330 – Orthotics and Prosthetics / Hearing Services      670 – Ambulatory Surgical Center / Birthing Center        972-GAPP
370 – Emergency Ground Ambulance Services               680 – Mental Retardation Waiver **
                                                                                        .
                                                                                                                                           Doc Type: 7104
Dialysis-Professional (Contract 720) Applicants ONLY: Please indicate whether the services rendered at the Service Location Address provided
on this application will be performed at a Hospital-Based facility? If the services will NOT be performed at a Hospital-Based facility, then the facility’s
CLIA Certification and Medicare Certification are REQUIRED supporting documents for this application.
DME (Contract 320) Applicants ONLY: Please indicate whether the applicant will provide Custom Wheelchairs? If YES, then Custom Wheelchair
Certification is a REQUIRED supporting document for this application.
                                                                   Specialty Code Valid Values
        005   Adult Day Health Care                         087   Home Delivered Services                       247 School Nurse
        010   Alternative Living Services                   088   Home Health Agency                            248 Skilled Nursing / Extended Care
        011   Ambulance Company, Licensed                   090   Hospice Facility                              249 Skilled Nurse Services
        012   Ambulance Company, non-license                091   Hospital, Regular General                     251 Speech-Language Pathology
        013   Ambulatory Surgery                            092   Hospital, Military                            252 Speech Therapy
        019   Audiology Services                            093   Hospital, Psychiatric, Freestanding           255 Substance Abuse Treatment Facility
        022   Birthing Center                               094   Hospital, Specialized Long Term               259 Supported Employment
        030   Case Management                               095   Hyperbaric Facility, Freestanding             260 Swingbed Hospital
        040   Community Health Centers                      099   Independent Lab                               261 Targeted Case Management
        044   Day Habilitation                              144   Nursing Home / Domiciliary Facility           266 Traumatic Brain Injury
        045   Day Treatment Services                        145   Nutrition                                     272 Residential Training and Super
        046   Dedicated Case Management                     151   Occupational Therapy                          273 Medical Supplies
        056   Dialysis, Technical                           197   Personal Support                              274 Institutional Based
        057   Disproportionate Share Hospital               201   Physical Therapist                            275 Vehicle Adaptation
        058   Durable Medical Equipment Supp                236   Rehab Services, DSPS                          276 Day Support Services
        060   Early Intervention, Agency                    239   Rehabilitation Medicine                       289 Behavioral Management
        064   Emergency Response System                     240   Renal Dialysis Center                         294 Natural Support Enhancement
        067   Environmental Modifications                   242   Residential Modification Service              295 Natural Support Therapy
        071   Family Planning                               243   Respite Care, In Home                         501 Custom Made Wheelchairs
        082   Health Check, Health Dept                     244   Respite Care, Out of Home                     504 Critical Access Hospital
        086   Home Delivered Meals                          246   Rural Health
D. Licensure
License information is required based on the Contract(s) for which you are applying. Please include ALL state licenses, past and present. If this information is not
applicable for your practice, please indicate by marking the “N/A” checkbox. Attach additional sheets if necessary.
E. Certification
Certification information may be required based on the Contract(s) for which you are applying. If this information is not applicable for your practice, please indicate by
marking the “N/A” checkbox. Attach additional sheets if necessary.
Medicare Information: Provide Medicare participation information. Your Medicare information must be on file if you wish to receive Medicare crossover payments.
Dialysis-Technical (Contract code 721) Applicants ONLY: If the services at the physical address listed on this application will NOT be performed at a Hospital-
Based facility, then the facility’s Medicare Certification and CLIA Certification are REQUIRED supporting documents for this application.
Liability Insurance Amount: Attach a copy of proof of liability insurance. Orthotics and Prosthetics/Hearing Services (Contract code 330): This field is required
and a copy of the current certificate is a required supporting document.
CLIA Number: Clinical Laboratory Improvement Amendment certification is required if you will bill laboratory procedure codes at this location. If this information is
not applicable for your practice, please indicate by marking the “N/A” checkbox. Dialysis-Technical (Contract code 721) Applicants ONLY: If the services at the
physical address listed on this application will NOT be performed at a Hospital-Based facility, then the facility’s CLIA Certification and Medicare Certification are
REQUIRED supporting documents for this application.
DEA Number: Providers who possess DEA permits are required to provide this information. If this information is not applicable for your practice, please indicate by
marking the “N/A” checkbox.
F. Other Medicaid Programs
Provide information regarding participation in other state’s Medicaid programs, past and/or present. If this information is not applicable for your practice, please
indicate by marking the “N/A” checkbox.
G. Languages: Indicate any languages that are spoken at the practice location.
              BA        Bangla                                    CC        Cambodian/Campuchean                     CH         Chinese (Mandarin)
              CZ        Czech                                     EN        English                                  FA         Farsi
              FP        Filipino                                  FR        French                                   GE         German
              HI        Hindi                                     IN        Indian                                   IT         Italian
              JA        Japanese                                  KO        Korean                                   LA         Laotian
              NA        Navajo                                    PO        Portuguese                               RU         Russian
              SA        Slavic                                    SL        American Sign Language                   SP         Spanish
              SW        Swahili                                   TA        Taiwanese                                TU         Turkish
              VN        Vietnamese                                ZZ        Other
H. Other Information: Bed Data: This information is required of applicants attempting to participate in the following contracts: Hospital (010, 070), Swing-beds (080),
Nursing Homes (110, 140, 150, 160, 170, 180)..
I. Practice Type Code: Select ONLY ONE of the choices that best describes the practice you will be providing services for named practice at the service location listed
on the first page of the application. If “Other” is selected, please clarify in the space available.
J. Correspondence Medium:
a. Correspondence receiving letters (including rosters, if applicable) by paper is ONLY available to applicants who are not capable of receiving information in an
electronic format.
b. Receiving bulletins by paper is ONLY available to applicants who are not capable of receiving information in an electronic format.
c. Receiving remittance advices by paper is ONLY available to applicants who are not capable of receiving information in an electronic format. The X12-835 option
requires that you have a contract with a clearinghouse.
d. PES requires special software, which is available through HP Enterprise Services - EDI Services. For more information, call (866)261-8785.


Rev. 1/2012                                                       All fields marked with * are REQUIRED
                                                                                                                                                         Doc Type: 7104
K. Managing Relationships: As required by 42 CFR 1002.3, providers must disclose the following for each individual officer, director, agent, managing employee
(general manager, business manager, administrator), and Electronic Funds Transfer (EFT) authorized individual. Failure to provide the required information may result
in a denial for participation.
If space is needed for additional Managing Relationships, please include the “Managing Relationships-Additional” form available at www.mmis.georgia.gov in the
Provider Enrollment section.
L. Ownership and Control Information: Disclose Owner(s) of your practice:
“Owner” means a person or corporation with an ownership or control interest that:
           1. Has an ownership interest totaling 5 percent or more in a disclosing entity;
           2. Has an indirect ownership interest equal to 5 percent or more in a disclosing entity;
           3. Has a combination of direct and indirect ownership interests equal to 5 percent or more in a disclosing entity;
           4. 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;
           5. Is an officer or director of a disclosing entity that is organized as a corporation; or
            6. Is a partner in a disclosing entity that is organized as a partnership.
If space is needed for additional Ownership and Control Individual’s Information, please include the “Ownership and Control Information Additional” form available at
www.mmis.georgia.gov in the Provider Enrollment section.

M. Exclusion / Sanction Information: This section is for exclusion and/or sanction information. Please provide accurate information regarding previous and current
exclusions and sanctions. All questions must be answered and clarified if YES.

N. Certification & Signature: Applications and supporting documentation for Facility applicants requiring an original signature must be signed by an authorized agent
of the facility.

Special Instructions - Please read thoroughly before completing this application. It is recommended that a pen with black or
blue ink be used and print legibly. Applications that are copies or faxes, incomplete, or unreadable will not be accepted or
processed.


Address to Mail your completed application and supporting
documentation:

HP Enterprise Services
Provider Enrollment
P.O. Box 105201
Tucker, GA 30085-5201

Address to use for private courier delivery of your completed application
and supporting documentation:

HP Enterprise Services
Provider Enrollment
100 Crescent Centre Parkway
Suite 1100
Tucker, GA 30084
A FAQ for Providers is available at http://www.mmis.georgia.gov , in the Provider Information
drop-down selection that addresses many common inquiries regarding Provider Enrollment as
well as information for enrolled Providers.

Rev. 1/2012                                                         All fields marked with * are REQUIRED
                                                                                                                                                                             Doc Type: 7104
                                      Date Received:                        OIG                      EPLS                              DMF                                 ATN
Department
 Use Only:                                                              No  Yes             No  Yes                        No  Yes

                                                         GEORGIA DEPARTMENT OF COMMUNITY HEALTH
                                                         FACILITY PROVIDER ENROLLMENT APPLICATION
A. Applicant Base Information                                                                                                           NPI #:*

Legal Business Name:

“Doing Business As” Name:

Type of Facility:(see instructions                                                             State Where
for list of valid values)                                                                      Incorporated:
Does this organization operate other sites,                             If YES, where?
locations, or units?                                   No  Yes
B. Address Information
    1. Service Location (Physical) Address*
Name of Practice:
(if applicable)
Street Address:*                                                                                                                                                Suite:
(PO Box NOT Acceptable)

City:*                                                                   County:*                                                       State:*                 Zip +4:*

Office Phone:*                                           Office Fax:                                                After-Hours Phone:

Office Email:                                                                                   Office Website:
(if available)                                                                                  (if available)

Is this location open 24 hours?  Yes  No                                         Is this location TDD/TTY equipped?                  Yes  No
     2. Payee Designation*
Enter the Legal Business Name, Georgia Medicaid Payee ID (if known), and Tax ID numbers associated with the practice the applicant will be rendering services for.
This Payee ID can be found on the top right corner of the existing Payee’s Remittance Advice. If a Payee number has NOT been established, please write the Legal
Business name (as shown on your IRS tax documentation) and Tax ID Number below. Tax ID number must be on the application or it will be returned. You may leave
the Payee ID field blank. Form W-9, EFT Agreement, and IRS Tax ID verification (147-C, CP575-A, etc. available from the IRS) are required supporting documents and
a new Payee ID will be created as part of the enrollment process.
Payee Legal                                                                                Payee ID                                                        Tax ID
Business Name:*                                                                            Number:                                                         Number:*
    3. Correspondence Address                                   Check N/A if correspondence address is the same as the physical address listed on this application                    N/A
ATTN TO:
(if applicable)
Street Address/ PO Box:                                                                                                                                         Suite:

City:                                                                    County:                                                        State:                  Zip +4:

Phone:                                                   Fax:                                                       After-Hours Phone:

Email:                                                                                          Website:
(if available)                                                                                  (if available)

      4. Person to Contact in Regards to this Application*                                                                                                                    Same as Above
Contact Person’s                                                                                                  First:                                                    MI:
     Name (Last):
Title:                                                          Telephone Number:                                                            Fax Number:

Email Address:

C. Program Enrollment Information (see Instructions for valid code values)
Provider Type Code:*             a. Contract Code:*                                                              Specialty Code:*
(see instructions)               (see instructions)                                                              (see instructions)
                                 b. Contract Code:                                                               Specialty Code:

                                 c. Contract Code:                                                               Specialty Code:

Dialysis-Technical (Contract 720) Applicants ONLY: Will the services rendered at the Service Location Address
provided on this application be performed at a Hospital-Based facility? If NO, then CLIA Certification and Medicare Certification                                            Yes     No
are REQUIRED supporting documents for this application.
DME (Contract 320) Applicants ONLY: Will the applicant provide Custom Wheelchairs? If YES, then Custom                                                                       Yes     No
Wheelchair Certification is a REQUIRED supporting document for this application.




Rev. 1/2012                                                               All fields marked with * are REQUIRED
                                                                                                                                                                Doc Type: 7104
D. Licensure
Licensing Entity*

License                                                            State*:                       Effective Date*:                           Expiration Date*:
Number *:

Do You Have Any Public Board Orders?*                  Yes    No                               If Yes, Date of Last Order:

E. Certification – Attach additional sheets, if necessary                                                                                                                   N/A
Certifying Entity 1:

Certificate                                                          State:                  Effective Date:                             Expiration Date:
Number:
Certifying Entity 2:

Certificate                                                          State:                  Effective Date:                             Expiration Date:
Number:
Medicare Provider                                                                            Effective Date:                             Expiration Date:
Number:
Medicare Carrier / Intermediary Name:
                                                                                                                                                      Part A    Part B
 N/A
Liability Insurance Amount (Include Copy of Certificate):
 N/A
CLIA Number:                                                                                 Effective Date:                             Expiration Date:
(If number entered, please include certificate)

Providers who possess DEA permits are required to provide a copy of the certificate with the enrollment application.                                                        N/A
DEA Number:                                                                                  Effective Date:                             Expiration Date:

All Schedules? (2, 2N, 3, 3N, 4, 5)                Yes    No

F. Other Medicaid Programs*                                                                                                                                                 N/A
1) Medicaid ID Number:                                                             State:
                                                                                                                                  Current Status:     Active    Inactive
Type of Service:                                                                             Effective Date:                             End Date:

End Date Reason:

2) Medicaid ID Number:                                                             State:
                                                                                                                                  Current Status:     Active    Inactive
Type of Service:                                                                             Effective Date:                             End Date:

End Date Reason:

3) Medicaid ID Number:                                                             State:
                                                                                                                                  Current Status:     Active    Inactive
Type of Service:                                                                             Effective Date:                             End Date:

End Date Reason:

G. Languages – List all languages spoken by the Provider.
Primary:                                                               2.                                                         3.


H. Other Information                                                                                                                                                        N/A
Licensed Beds:                                                                               Available Total Beds:

Male:                                                                                  Female:                                            Either:
                                                                                                                                          :
I. Practice Type (Select ONLY One) *
    Corporation                                                      Public Clinics                                           Teaching Provider
    Group Practice (PRIVATE)                                         Health Maintenance Organization                          Not Applicable
    Hospital-Based Physician                                         Partnership or Professional Organization                 Other:
    Individual Practitioner                                          Pre-Paid Group Practice Plan
J. Correspondence Medium *
a. Letter Medium                           Paper                 Email Link                                     Fax                       Web Portal Message Center

b. Bulletin Medium                         Paper                                   Web Portal Message Center

c. Remit Medium                            Paper                                   Web Portal Message Center                          X-12-835 via Clearinghouse
d. Billing Medium                          Paper                 Batch                     Web Portal Message Center                 PES*
*PES requires special software which is available through HPES, EDI Services. For more information call (866) 261-8785




Rev. 1/2012                                                                   All fields marked with * are REQUIRED
                                                                                                                                   Doc Type: 7104
K. Managing Relationships*
As required by 42 CFR 1002.3, providers must disclose the following for each individual officer, director, agent, managing employee (general
manager, business manager, administrator), and Electronic Funds Transfer (EFT) authorized individual. Failure to provide the required information
may result in a denial for participation.
In addition to yourself, do you have any managing relationships? *    Yes    No      If yes, list all below
 1.     Full Name                                                                                                  Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 2.     Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 3.     Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 4.     Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 5.     Full Name                                                                                                  Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 6.     Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 7.     Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 8.     Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 9.     Full Name                                                                                                  Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
 10.    Full Name                                                                                                 Date of Birth
        (Last, First, Middle) *                                                                                   (MM/DD/CCYY) *
Social Security                                                         Familial Relationship to Enrolling Provider
Number *                                                                (i.e., Mother, Father, Sister, Brother, None, etc) *
Business Relationship to                                                 DEPT USE         POA ID:
Enrolling Provider (Title) *                                              ONLY
If space is needed for additional Managing Relationships, please include the “Managing Relationships-Additional” form available at
www.mmis.georgia.gov in the Provider Enrollment section.



Rev. 1/2012                                                    All fields marked with * are REQUIRED
                                                                                                                                                 Doc Type: 7104
L. Ownership and Control Information
How would you describe the ownership? (Select ONLY One) *
                                                                                        Sole Proprietor (Individual filing under an EIN)
                          Self (Individual filing under a SSN)                         Partnership
                          Single-Owner LLC
                                                                                        Corporation
Corporations, Partnerships, and Sole Proprietors:
What percentage of shares / ownership do you have? ________________
Does anyone have direct or indirect ownership or control interest of 5% or more in the organization/entity? *  Yes  No
If you answered yes to the above question you must list ownership information for each owner who owns 5% or more.
 1.      Full Name                                                                                                       Date of Birth
         (Last, First, MI) *                                                                                            (MM/DD/CCYY) *
Social Security                                                            Familial Relationship to Enrolling Provider
Number *                                                                   (i.e., Mother, Father, Sister, Brother, None, etc) *
Organizational Owner Name:                                                                                Tax ID:
(If not Individual)                                                                                       (If different than Applicant)
Business Relationship to                                                    DEPT USE         POA ID:
Enrolling Provider (Title) *                                                 ONLY
Does the owner have ownership or controlling interest in another entity or organization that is enrolled in Georgia Medicaid? * (42 CFR
455.104(b)(3) : The name of any other disclosing entity (or fiscal agent or managed care entity) in which an owner of the disclosing              Yes  No
entity (or fiscal agent or managed care entity) has an ownership or control interest.)
If the answer to the above is “Yes”, provide the Name of Entity, Street Address, City, State, Zip Code and Percentage of Ownership in the space below. If additional
space is needed, please provide these details on a separate sheet.



 2.      Full Name                                                                                                       Date of Birth
         (Last, First, MI) *                                                                                            (MM/DD/CCYY) *
Social Security                                                            Familial Relationship to Enrolling Provider
Number *                                                                   (i.e., Mother, Father, Sister, Brother, None, etc) *
Organizational Owner Name:                                                                                Tax ID:
(If not Individual)                                                                                       (If different than Applicant)
Business Relationship to                                                    DEPT USE         POA ID:
Enrolling Provider (Title) *                                                 ONLY
Does the owner have ownership or controlling interest in another entity or organization that is enrolled in Georgia Medicaid? *                   Yes  No
If the answer to the above is “Yes”, provide the Name of Entity, Street Address, City, State, Zip Code and Percentage of Ownership in the space below. If additional
space is needed, please provide these details on a separate sheet.



 3.      Full Name                                                                                                      Date of Birth
         (Last, First, MI) *                                                                                            (MM/DD/CCYY) *
Social Security                                                            Familial Relationship to Enrolling Provider
 Number *                                                                  (i.e., Mother, Father, Sister, Brother, None, etc) *
Organizational Owner Name:                                                                                Tax ID:
(If not Individual)                                                                                       (If different than Applicant)
Business Relationship to                                                    DEPT USE         POA ID:
Enrolling Provider (Title) *                                                 ONLY
Does the owner have ownership or controlling interest in another entity or organization that is enrolled in Georgia Medicaid? *                   Yes  No
If the answer to the above is “Yes”, provide the Name of Entity, Street Address, City, State, Zip Code and Percentage of Ownership in the space below. If additional
space is needed, please provide these details on a separate sheet.



 4.      Full Name                                                                                                      Date of Birth
         (Last, First, MI) *                                                                                            (MM/DD/CCYY) *
Social Security                                                            Familial Relationship to Enrolling Provider
Number *                                                                   (i.e., Mother, Father, Sister, Brother, None, etc) *
Organizational Owner Name:                                                                                Tax ID:
(If not Individual)                                                                                       (If different than Applicant)
Business Relationship to                                                    DEPT USE         POA ID:
Enrolling Provider (Title) *                                                 ONLY
Does the owner have ownership or controlling interest in another entity or organization that is enrolled in Georgia Medicaid? *                   Yes  No
If the answer to the above is “Yes”, provide the Name of Entity, Street Address, City, State, Zip Code and Percentage of Ownership in the space below. If additional
space is needed, please provide these details on a separate sheet.



If space is needed for additional Ownership and Control Individual’s Information, please include the “Ownership and Control Information -
Additional” form available at www.mmis.georgia.gov in the Provider Enrollment section.


Rev. 1/2012                                                    All fields marked with * are REQUIRED
                                                                                                                                        Doc Type: 7104
M. Exclusion / Sanction Information * (Use additional sheets if necessary)
For the following questions, the word “you” and “your” shall mean the enrolling provider, its owners, and its agents in accordance with 42 CFR
455.100; 101; 102; 104; 105; 106 and 42 CFR 1001.1001 et seq.:
    * An agent is defined as any person who has been delegated the authority to obligate or act on behalf of a provider. This includes, but is not limited
to, managing employees, Board Members and Electronic Funds Transfer (EFT) authorized individuals.
    * A managing employee is defined as 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 the enrolling provider.
    * An entity shall include, but not be limited to, a corporation, limited liability company, partnership, business, provider organization, or
professional association.
Note: All applicable adverse legal actions must be reported, regardless of whether any records were expunged or any appeals are pending.
1. Have you ever been convicted of any criminal offense, had adjudication withheld on any criminal offense, pled no
                                                                                                                                       Yes  No
    contest to any criminal offense or entered into a pre-trial agreement for any criminal offense?
2. Have you, or any entity, agent, owner, or managing employee ever had disciplinary action taken against any business or
    professional license held in this or any other state, including licenses issued by the Department of Community Health              Yes  No
    (GA DCH)?
3. Has your license to practice ever been restricted, reduced or revoked in this or any other state or been previously found
    by a licensing, certifying or professional standards board or agency to have violated the standards or conditions relating
                                                                                                                                       Yes  No
    to licensure or certification or the quality of services provided, or entered into a Consent Order issued by a licensing,
    certifying or professional standards board or agency?
4. Have you, or any entity, agent, owner, or managing employee ever been denied enrollment, suspended, excluded,
    terminated, or involuntarily withdrawn from Medicare, Medicaid or any other government or private health care or                   Yes  No
    health insurance program in any state?
5. Have you, or any entity, agent, owner, or managing employee ever had payments suspended by Medicare or Medicaid
    in any state?                                                                                                                      Yes  No
6. Have you, or any entity, agent, owner, or managing employee ever had civil monetary penalties levied by Medicare,
                                                                                                                                       Yes  No
    Medicaid or other State or Federal agency or program, including GA DCH, even if the fine(s) have been paid in full?
7. Have Medicare or Medicaid in any state ever taken recoupment actions against you, any entity, agent, owner, or
                                                                                                                                       Yes  No
    managing employee?
8. Do you, or any entity, agent, owner, or managing employee owe money to Medicare or Medicaid that has not been paid
                                                                                                                                       Yes  No
    in full?
9. Have you ever been convicted under federal or state law of a criminal offense related to the neglect or abuse of a patient
                                                                                                                                       Yes  No
    in connection with the delivery of any health care goods or services?
10. Have you ever been convicted under federal or state law of a criminal offense relating to the unlawful manufacture,
                                                                                                                                       Yes  No
    distribution, prescription, or dispensing of a controlled substance?
11. Have you ever been convicted under federal or state law of any criminal offense relating to fraud, theft, embezzlement,
                                                                                                                                       Yes  No
    breach of fiduciary responsibility or other financial misconduct?
12. Have you, or any entity, agent, owner, or managing employee been found to have violated federal or state laws, rules
    or regulations governing Georgia’s Medicaid program or any other state’s Medicaid program or any other publicly                    Yes  No
    funded federal or state health care or health insurance program?
N. Certification and Signature
To the best of my knowledge, the information supplied in this document is true, accurate and complete and is hereby released to the Georgia
Department of Community Health, Division of Medical Assistance for the purpose of issuing a Medicaid provider number. I understand that
falsification, omission or misrepresentation of any information in this enrollment package will result in a denial of enrollment, the closure of current
enrollment, and the denial of future enrollment requests, and may be punishable by criminal, civil or other administrative actions. I understand that my
signature certifies that I have read the manuals, Parts I, II, and III (if applicable), for the Contract(s) indicated herein and I authorize Medicaid or its
authorized representative to verify this information.
                                             Information Must Be Entered For The Agreement To Be Processed
Print Name *                                                                                                  Title *




Signature of Facility Administrator or Authorized Agent *                                                     Date *




Rev. 1/2012                                                All fields marked with * are REQUIRED

				
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