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Disclosure of ownership bcbs Form: What You Should Know

SUBJECT: Provider Disclosure of Ownership and Control Statement/Determination The providers below disclose ownership or control of any individual or entity as follows: (A) A medical supplier, (B) A provider of medical/surgical supplies and equipment, (C) A professional health service/benefits provider for individuals with disabilities, (D) A provider of medical/surgical supplies and equipment that provides health care to individuals with psychiatric disabilities, (E) A provider of medical/surgical supplies and equipment that provides health care to individuals with drug/alcohol use disorders, (F) A provider of medical/surgical supplies and equipment that provides health care to individuals with trauma, (G) A provider that is not employed by the provider's employer, (H) An independent contractor of the above providers or the provider's employers (I) A provider of medical/surgical supplies and equipment that offers health care to individuals with other disorders, and (J) A medical or surgical supplier. No individual or entity that is not a healthcare provider may disclose the identity of their specific employees. Disclosure of Ownership and Control Letter: If not a person or business, please identify the individual or entity that has control over this provider's activities. (See enclosed letter.) List any other individuals with a direct or indirect interest in the provider or supplier's activities. If the provider is a person, please identify the person's name, role and contact information. (D) list any other persons who control or are involved in the provider's activities; or  (E) list the nature of the relationship or involvement between the provider and the person listed in (I-J). List the names of all individuals with whom you have communicated with regarding this listing, their contact information (phone # and email) and any relationship of any kind between you and such individuals. (F) For each individual you have been in contact with about this listing, list the following; (e) Name and location of their provider. (f) Name of their employer. You also will need to include, in all letters, a list of all contracts between this provider and any entity, partnership, joint venture, limited liability partnership, or other entity which the provider has a contractual relationship with. These can include any organization, including, if applicable, a federal, state, or local government.

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