Edit, Download, and Sign the Disclosure Form for Provider Entities
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How do I fill this out?
Filling out the Disclosure Form requires attention to detail. Ensure that all relevant information about the provider entity is accurately captured. Be sure to provide complete details for significant changes like ownership or location.
How to fill out the Disclosure Form for Provider Entities?
1
Complete all identifying information accurately.
2
Provide ownership and control details as required.
3
Answer all specific questions in the form.
4
Attach any additional sheets if necessary.
5
Ensure no questions are left blank, and review before submission.
Who needs the Disclosure Form for Provider Entities?
1
Healthcare providers needing a new Medicaid ID number.
2
Entities re-credentialing for TennCare services.
3
Businesses with ownership changes in their provider entity.
4
Organizations expanding their services or locations.
5
New providers entering the Medicaid system for the first time.
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What are the instructions for submitting this form?
To submit this form, please return it to the address specified in the application packet. Alternatively, you can submit it via fax or email, if available. Ensure that all sections are completed accurately and submit it as soon as all necessary information is gathered for timely processing.
What are the important dates for this form in 2024 and 2025?
Important dates for the submission of this form include the end of each quarter when credentialing reviews occur. Additionally, ensure submissions are made prior to any annual reviews for ongoing credentials. Updates to requirements may also be announced, so staying informed through official channels is essential.
What is the purpose of this form?
The purpose of this form is to collect crucial information about Provider Entities seeking TennCare/Medicaid identification. This includes ownership details, service locations, and operational changes. Accurate completion of this form ensures compliance with state regulations and facilitates the processing of applications.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Entity Name: The legal name of the business entity applying for the Medicaid ID.
- 2. Federal Tax Id Number: The tax identification number assigned to the Provider Entity.
- 3. NPI Number: The National Provider Identifier number for the entity, if applicable.
- 4. TennCare/Medicaid ID Number: Identifying number assigned to the Provider by TennCare.
- 5. Owner Information: Details regarding individuals or entities that have ownership stake.
What happens if I fail to submit this form?
Failure to submit this form can lead to significant delays in obtaining necessary credentials for operating within the TennCare system.
- Delayed Processing: Inadequate information may cause processing delays, affecting service provision.
- Compliance Issues: Non-submission could lead to non-compliance with state regulations and potential penalties.
- Loss of Service Providers: Failure to maintain proper documentation may jeopardize contracts with TennCare.
How do I know when to use this form?
- 1. New Applications: For new providers entering the TennCare system.
- 2. Re-credentialing: Needed for existing providers during the renewal cycle.
- 3. Ownership Changes: Must be submitted when ownership stakes shift within the entity.
- 4. Location Changes: Essential for providers moving to new service locations.
- 5. Management Changes: Used when there are changes in key management personnel.
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