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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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