Group Provider Enrollment (Ownership) Page

You use the Ownership page to add or edit the group provider's ownership information to the enrollment application.

Ownership- Section 7 Fields

Field Description

Ownership Fields

1. How many owners of this application have a 5% or more ownership interest in the group?

The total number of owners with 5% or more ownership interest in the group in the field provided.

If you enter a number other than zero, additional fields are displayed for you to add or edit ownership information.
To add new ownership information, click Add Ownership. Existing ownership information, if any, is listed in a table. To edit, in the Ownership table, click the appropriate table row. After changing or adding new ownership information, on the Ownership action bar, click Save.
Is the Owner an Individual or Group?

When adding an owner, select if the owner is an individual or group.

Depending on which answer you select, additional fields are displayed for you to enter individual or group ownership information. Field descriptions for both options are listed below.

Tip: This field is only displayed when you add ownership information. If you saved the information after choosing the wrong option, you must delete the incorrect entry in the table and add a new one.
Individual Selected As Owner
Last Name Individual owner's last name.
First Name Individual owner's first name.
MI Individual owner's middle initial.
Title Individual owner's official title.
Doing Business (DBA) As Name Official name under which the individual owner is doing business.
Effective Date of Ownership

Date the ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select.
Date of Birth

Individual owner's date of birth.

Format: MM/DD/YYYY, or click the calendar to select.
Country/State of Birth State or country in which the individual owner was born.
SSN

Social Security Number of the individual owner.

Format: ###-##-####
NH Title XIX Provider ID The individual's current Medicaid provider number.
Group Selected As Owner
Business Name Business name under which ownership is held.
Doing Business As (DBA) Name Official name under which the organization is doing business.
FEIN The group's Federal Employer Identification number.
Effective Date of Ownership

Date the ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select.
NH Title XIX Provider ID The group's current Medicaid provider number.

Relative/Household Member Fields

2. Are any of the persons with an ownership or controlling interest in the provider's company related to one another as spouse, parent, child, sibling or household member?

Select Yes or No to indicate if there are any persons with an ownership or controlling interest in your company related to one another.

If you select Yes, additional fields are displayed for you to complete.
To add new relatives, click Add Relative/Household Member. Existing relatives, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding new ownership information, on the Relative action bar, click Save.
Last Name Last name of the relative or household member who holds the ownership and/or controlling interest.
First Name First name of the relative or household member who holds the ownership and/or controlling interest.
MI Middle initial of the relative or household member who holds the ownership and/or controlling interest.
Relationship The owner's relationship to the relative or household member who holds the ownership and/or controlling interest.

Managing/Directing Employees Fields

3. What is the total number of managing/directing employees for the group?

Enter the number managing/directing employees for the group.

If you enter a number other than zero, additional fields are displayed for you to add or edit managing/directing employee information.
To add new managing/directing employee information, click Add Employee. Existing employees, if any, is listed in a table. To edit, in the Employee table, click the appropriate table row. After changing or adding employees, on the Employee action bar, click Save.
Last Name Last name of the managing/directing employee.
First Name First name of the managing/directing employee.
MI or Middle Initial Middle initial of the managing/directing employee.
Title Title of the managing/directing employee.
Date of Birth

The date of birth of the managing/directing employee.

Format: MM/DD/YYYY, or click the calendar to select.
SSN

Social Security number of the managing/directing employee.

Format: ###-##-####
Country/State of Birth State or country in which the managing/directing employee was born.
4. Has this managing/directing employee ever had a Title XIX provider number in this or any other state?

Select Yes or No to indicate if the managing/directing employee has ever had a Title XIX provider number in this or any other state.

If you select Yes, additional fields are displayed for you to complete.
Business Name Organization's legal business name as it appears in IRS forms.
Effective Date

Date when the organization began operating under the legal business name.

Format: MM/DD/YYYY, or click the calendar to select.
End Date

Date when the organization ends operating under the legal business name.

Format: MM/DD/YYYY, or click the calendar to select.
SSN/FEIN The employee's Social Security number or the organization's Federal Employer Identification number.
Current Title XIX Provider # The current Medicaid provider number.
State The State that issued the current Title XIX provider number.
Prior Title XIX Provider # The prior Medicaid provider number.
State The State that issued the prior Title XIX provider number.

Subcontractor Relative Fields

5. Do any of the members of your immediate family (spouse, parent, child, sibling) have ownership of 5% or greater in a subcontractor to your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/provider has contracted responsibilities of providing medical care to its patients.)

Select Yes or No to indicate if you have any immediate family members who hold a 5% or greater ownership in a subcontractor to your business or practice.

If you select Yes, additional fields are displayed for you to complete.
To add new relatives, click Add Relative/Household Member. Existing relatives, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding new ownership information, on the Relative action bar, click Save.
Last Name Last name of the relative or household member who has ownership in the subcontractor business or practice.
First Name First name of the relative or household member who has ownership in the subcontractor business or practice.
MI Middle initial of the relative or household member who has ownership in the subcontractor business or practice.
Relationship Relationship of relative or household member to the owner of the subcontractor business or practice (spouse, parent, sibling, etc.).
Subcontractor Name Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients that is associated with the relative.
Address Physical street address of the subcontractor associated with the relative.
City City where the subcontractor associated with the relative is located.
State State where the subcontractor associated with the relative is located.
Zip Zip code and extension where the subcontractor associated with the relative is located.