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Disclosure of ownership cms 1513 Form: What You Should Know
Disclosure of Ownership and Control Interest Statement is required at the time of application, application renewal, and application for a new Medicare/Medicaid facility or to re-file. (See Form 2047-D — Federal Register, Vol. 66, No. 114, Fees and Expenses (Effective 12/01/2015) — Medicare Program.) The individual or organization must also be a Federal or State, tribal or local government entity; a nonprofit, charitable organization; or a private, not- for-profit corporation established for nonprofit, charitable, or political purposes. The form must be completed and signed by the head of the organization or the agent for service of process, and on the form, include and state the name(s) of the entity. The completed form is submitted electronically by submitting it via e-mail to (See the instructions for completing e-mail and paper disclosure requests) C. If you have additional information on the owner or manager; (See instructions for completing disclosure of owner and management interest statement in Form D-56 — Federal Register, Vol. 66, No. 109, Item (14), Medicare—Medicare Part D, Payments and Coverage.) F. If any of the following information is not correct, there is no owner or individual; (See instructions for completing disclosure of owner and control interests in form D-55 — Federal Register, Vol. 66, No. 123, Item (4), Medicare—Medicare Part D, Payments and Coverage.) The organization or company has no control of the facility, as indicated on Form 2047-D-3S— Federal Register, Vol. 66, No. 114, Fees and Expenses (Effective 12/01/2015) and payment information as indicated on Form 2047-D-3A—federal register, vol. 66, No.
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