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Cms disclosure of ownership Form: What You Should Know

Address (Street Address, City, State, ZIP, Zip Code) 2. Ownership or Control Interest. List the name and the type of interest (e.g. Sole proprietorship, LLC, General Partnership, or Corporation) 3. Ownership or Control Interest. (a) Disposition or Ownership interest in the Hospital. List the name and the type of ownership interest involved and the name of the person or persons having a financial interest in it.  Example: S&L name, S&L account, mutual fund or mutual insurance (b) Disposition or Ownership interest in the Provider in the event of a merger, conversion, reorganization or other event of dissolution (e.g. Bankruptcy) 4. Ownership or Control Interest. (a) D.O.B. Date of Birth of the individual being sought after a person has been admitted to, or has become an employee of, the hospital (b) SSN. Age of individual, if younger than  16 years of age, or older than  16 years of age 5. Ownership or Control Interest. (a) D.O.B. and SSN of the individual being sought or that individual's parents or guardians. (b) Date the individual being sought began to be employed by the Hospital or became an employee of the Hospital, as relevant.  Example: On or about January 21, 2015, this individual was first employed by the Hospital and continued to work continuously for the Hospital through July 19, 2016, by virtue of his position, status, and length of service. (c) D.O.B. and SSN of the individual being sought, if other than the individual being sought as above. (d) D.O.B. and SSN of any individual being sought of which other information is known, but that information is not required to be disclosed. (e) Telephone Number (e.g., ) of the individual, if other than the individual being sought.

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