PT12-OlSTATE OF MARYLAND

DHMH Office of Health ServicesMedical Care Programs

Maryland Department of Health and Mental Hygiene201 W. Preston Street. Baltimore, Maryland 21201Parris N. Glendening, Governor - Georges C. Benjamin, M.D., Secretary

MARYLAND MEDICAL ASSISTANCE PROGRAMNursing Home Transmittal No. 168

December 29,2000

Nursing Home Administrators

Joseph M. Millstone, Executive Director ~1 Yl1

Office of Health Services PFROM:

A BILLING PROCEDURE CHANGE IS INCLUDED IN nus TRANSMI1T ALNOTE:

Enrollment of Medicaid Nursing Home Providers as Therapy Providers in Order toBill for Medicare Deductibles and the 20 Percent Coinsurance

Due to consolidated billing, nursing home providers must bill Medicare directly for allphysical, occupational and speech therapy services rendered to Medicare recipients, includingthose who are also Medicaid eligible. Also, as of October 1, 1999, these costs incurred fo.rMedicaid recipients have not been allowable on providers' cost reports. To date, there has notbeen a mechanism available for providers to be reimbursed by Medicaid for Medicaredeductibles and coinsurance for dually eligible recipients.

Effective immediately, Medicaid nursing home providers may enroll with the MedicaidProgram as therapy providers solely for the purpose of billing for Medicare deductibles andcoinsurance. Nursing home providers should enroll as Provider Type 28 - Therapy GroupProvider and list individual specialties for Physical Therapy, Occupational Therapy and SpeechTherapy with an enrollment status of 37 = Mcare Xover Only. The enrollment application is

enclosed.

Providers should bill on either the HCFA-1500 fonD or the UB-92 claim fonD (howeveryou bill to the Medicare intennediary) with an attached Medicare EOMB. The 9-month billingtime limitation will be waived back to October 1, 1999. Providers should submit all claimsbeyond the 9-month period as a group, with an attached identifying memorandum, to theattention of Charlotte Krueger, Claims Processing Division, Room 88-18. The deadline forsubmittin~ these "old" claims is June 30. 2001.

Toll Free 1-877-4MD-DHMH. TrY for Disabled - Maryland Relay Service 1-800-735-2258Web Sue: www.dhmh.state.md.us

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Any questions regarding this transmittal should be directed to the Nursing Home Sectionof the Division of Long Teml Care Services at (410) 767-1444, or to the Division of Children'sServices, which will process the provider applications, at (410) 767-1485.

JMM/sehEnclosure

cc: Nursing Home Liaison CommitteeCharlotte KruegerRose Ann Meinecke

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STATE OF MARYLANDDEPARTMENT OF HEALTH AND M£N'T Al. HYOIENE

MEDICAl. CARE nOCiRA.MPROVIDER APPUCA TlON FORM

am ~ ., ,.a. ~. It die ~I is to C'bInIC ew\IftI data. ItICn ,au mUll m¥rJaur MedicaMf Prvvidcr Number 81 die block foi»wIDI die Inv-- TIle auvUmcnt bep~ bo- ~..v.: 1ppjc8i8 is bu8d on Ibc dllC Ibc IppKab0ft4ll-- ~i~ mlhls0". If you Mw ..., ~ .,.a lad I.q~ bi!lan, ClplbiJlty pnor to die .~Ja8r appJicIt*I it ..a¥8d by Ibis officc. pl81C Ma~ . Rcqual8d EnroUmcnI IIIInDa~. BECAUSE OF THE NINE (91 MON'nf IIWNC UMrrA"ON for cllunslaba- ~ die Propam. ~ ~.v¥.r EmuUmcnI Scc1ion will oaJy bIct..~ your~~ ~ 01 moatbs prior to D neapl dale. In order to prcYaIllftc ~n ofda8I by Iftc PIa, - ~ DMIbllcftI 1aIaI. cnmUnlatI lhouJd ta&c pIacc ~ ~ i...,.. calC ~ ..."aad M8diCIJ ~.!2.!!-~ nc.-u. !

New EmaJbDCDl/CMaac 81 ;...~~~~~~~fROI'" EalVIaIIaIt Da~

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r-;- If ,au Mft . bUI8aS. Iucb u . pbInucy or .-aJ 11!ppI)', UIC dill b*k ~ act~ COIIII8ft)" All pbJIiciIDIlDd alia _ividUIl ~ IIIOuId a=u~, fin! -. 8iddk 8iIa1 ADd ~(a...11iIk. All prv(aliaall ~.-.w ~ .. corpaniC pogp _. ADDmONALL Y. PLEASE IDENTIFY AN,"O11IER OFFICE PERSON WHICH MAY SERVE AS YOUR POINT OF CONTACT

FOR QUEST10NS AND INQUIRIES.

~ or ~.v. 8r NaaICIOI-..C8II8Ct Prvp881

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E8r die C-,. s... ad Zip Code of Jaat ~ ~t8 ~ ,.. I8da' ~~.c.,/s.-'Z4>Codc

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ea.r your M--11icaIIC 8uaIbcr. bcpmma cficcuwc daIC and apua~ daleLiccnse Numbcr/Ucenle Da~Eapntion Date

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E.-r JO8f Pba.-cy pami1 aIabcr. it appbeablc--- -1~ PtlamlaCY Pennlt Nurnbct

bIdcpaIdCIIt Labora~rxa MUST G*r !tIC CJilucal Labon~ry lmplVv=-tA.fftatG.-taldauuat:lOn NutIIbcr. Pn~i~~Mn prv¥idUlI .borstor")' ICTV~ onIIXC~ onplatanl 81 UIC Slale or Maryland MUST enter a LaboraJDry PerautNumber. 'T1M CUA e8nir~abOn and/or Lab Pmnil MUST be lubIIIJu8d W1Ih diea~laeauon. if a~bcablc.

CUA Numbcr/l.ab PallIal Numecr13

OHMH XXXX.A,

PaOVlDD APPUCA.'nON INSTRUCTIONSPA.CE2

0ENcr ~r N I ~.idc; WauifJcr Number.NPI..~ e.r JOur DnII Enfol~~d AIaJCy Dunecr. If JOU do ~t Mft I DEA a8Dbcr. Ibu, b*k ~ be cft biult.

DEANIanbcrIS

E8ICr die appropria~ NO dilil codc for ,our '7PC of pacta. If Ihis docs nol apply.-" die block bleat. For,..., rcfaaec. a ... of" pncticc -- iI i"iV"".-'~ al~ - ofd8C 8tr-~~.

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I U,au arc appi1ial u an HMO. ac FR ~ aIdJca~ dIC Iypc or coanct u Fu1J bt~ Abon-. or SL ~ ~Ie Ibe Iypc of coa&nct u SlOp Lou wiIIIoul AbonioD.

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19 Pr-.IJ c.~bry !~a'" ~. -r. ..ip" die ~ 1pccIaJIry. If apccaJiIy co8Iaft CD8CIwd. ~ 7OU- .. .,.aJiry u Ibc pr-.ry 1peciaJiIy.

I 20 I S,.aiIy CodcPhyaCiaaa. DaIIiI1I and PbI~ MUST attcr die apprvpnaie du8 dIII&8 cadc &am~ ~~ Code iI&8I pruv~ at ~ aid or &bac 811UUC1»CU. EJI8Cr OTH it youhaft ..ctcr ~ ~t 111*. PLEASE SPECIFY.

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23 ~ or~ c. FOR DHMH USE ONLY. PLEASE DO NOT FD..L IN.

2A G1VUp M8IIbcn~ Haec. ProYiderNIIaIbcr. Belin Data

Ir JOU 8re 8 MEMBER OF A GROUP PRAC'ncE. ,... .., ~. M.".~M~ prv.- ..., .. 1iIip cfflCtivc .. for die pvup. It JOU 8ft 8GROUP PRAC'nCE. pkuc lilt die ..,.. or _dI prufaIXIftIJ pndicm, 81 JOur pap- ~ MaryIa8d Medicaid ~.idci nuI8bcr aed ~b::-.bip .1fec1iYC .~.

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Local H8JdI Dcpt. C1iaic Iad_- E-.. -y- - Y. if,... ., . Local HaMI D8pu8aII CI8IK

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21 SaJan8d IJIdIcalDr E8r -r - Y.II,., ~..,.. ~.. -d:-..IC_:'-,,-.-29 M~I School Aft'a1ia~ Ir,"" ,,-, . aml8- ~ a MMicaJ SdIOOI. alia' !tic -- uId addraI or dIc

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30 Raldcnn, Only IndiealOr En., -y- rot Ya if,vu ..nt ~ aroU as. -RcndcrmI Only- pnculioMr. If,vu-U as , ODIJ ,- p8JIIICDU wiU be IIIadc 81 (tic -- of 7OUr" POuP for die~ you ;;.;Icr":.

31 Ply 10 AddIas EIIIer Ihc 8ddt-. wtaKh you wiItI your M8d~ ~ _iMd. II you _ft thaebDcts blaak. your c*-tJ wW be a-.iI8d 10 &be pnCIIcc name aad add... ~ onIbc flnt pap ollbc applicalioft.

3~ EDICT !tIC addras wlucb you w'IIh aU yaur Mcdaid ftJalcd conapaaGalCc mailed. IIyou .." iliac bkJcts blaAt. =napoDdcllcc will be maikd to !tIC pnclice name andadd,., aaler.d on the fint ~.. of IiIc appbcalion.

Co~dcn" Addras

i 33 I Your Fiscal Year End PlcaIC a= die dale on whictl your fllcal yar CIIdJ CMMDD).

34 , or Bcds EJIfC!' UIc nuneer or b8is 8ppbcablc for 8ch ~ ~ ~

~DHMH XXXX-A

PRO\'IDER APPUCA TJON INSTRUCTIONS- PAGE:-

35-36

Labonlory ClassiflCallons FOR DHMH USE ONLY. PLEASE DO NOT FILL IN

rf you are participal1ftl in Medicare. please lisl the fISCal inlenncdl&rics with whom youare enrolled li.e. BI~ Cross of Maryland. Traveler's Group Hospilallnsurant'C TGHI.elc.' and enter the provider number each has assil"cd 10 you.

MedicaR Information

r 37 1 EJaettonie Claims Submusior Pleasc Indic81C if you ~uld likc to submit ~r ('laims ctcc1nmicaUy.

31 Other Pncticc location Jnlomlauon Please enler other ~alions where you servICe Maryland Medica! Assillancc ~enlSInclude aU Jrollp addras you arc currently pracucmJ under. IF APPLICABLE. Enlerthe License Number and ExpirallOn dale for each of these Iocalions. If out of stale,aaach . copy of. CUrlalI license

i 39 I AudlO~lion Picuc lap and dale Ihc appbca..on

40 PnJvidcr AFClnenl Plcase read and IiI" the Provider A,recmenl (or Panicipalion in the Tide XIX ProJramIRcndenn, only Pra,"litlOncn arc ex,"ludcd,

OHMH XXXX-A

PROVIDE. APPLICATION INSTKUCTIONS~AGE~

PROVIDER TYPE CODES

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PROVIDD APPUCA. nON INSB\JCt10NS- - !A.GES

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FOR DHMH USE ONLY

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II FEDERAL T AX NUMBER SOC1AL SECtJRITY NUMBER

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. STATE OF MARYLANDDEPARTMENT OF HEALTH AND MENTAL HYOIENE

MEDICAL CARE PROORAMPROVWER APPUCA nON FORM

IMPORTANT: PIraH rad &W: auaclwd Prorider lastradioas (DImDl )""A"A"X-A) w:rorr proceediaa.

I New Earou-I 0 R~r.s EnroUmeUI Begw Dare I I I I I I I

~, PaOVIOD APPLICATION INSTRUCTIO~

PAGE 2

PRACTICE INFOR~IA TION

"mlo n'PE CATEGORY

W"OWNERSHIP CODE

U~ OF PRAC'nCE

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."IIAI, rrfr,. 10 tJ" IN.sTRUcnONS fo,. "" approprilll, codIs.SPECIAUTY INFORMA nON

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-.Pilar, ,..".,. 10 th, lNSTRUcnONS for d" Gppropri4l, cod,s.

~ ~ ,,--;-~_il ;; ~ ~ s.v.. R8F~ (COMAR. 10.09.02). effectIVe July I. 1979. rhc M.sICal Alsia~ ProIr8m~ a C-.a s.-=-~ a a licaII.t JilysicIaD w~ ~ ~ of die foUowm, cnteria: (please check die appropriate s~l)

- I law t..1_J...t t..Id certifi«i by . ~ber of Ibe AIIIeric8n bid of Medical Spcciahst ...s cumDtIy retaID thar llam. A~':"~..:.~-~-~~-y of my I.-cIabty t..rd certificate II 8I18Cb.s.

- I uve aatilf8CloriJy COGif"~ . res~ P'OIrIm ace_I«! by tile Liajsc-. C~a. for ura.ae Medical ~1iOD or by~ ~ Res8ielK:y rwview C- -' "'- of ~ ~ M8iicaJ .A-.!l«I8ticm. Aa.d.t is . Ieu.r of verificaIiOD from thec~ of the deJ8r-.at wt.n I c.:~~l8Imy ra~ or w~ I am ~ workiD&. This lcaer ilx:kId. &be ~ of &bet..F8al ~ I-::-~~~ my ra"MiCDCy. ieII8d1 of my relKieDCy. by wtKJaa die P'OII8m IS .cc,.Ijt.s. aI.1lbe ~ dale ofmy r.Mieacy.

- J t.ve ~ decl8l.s tx.Id cerQra.I tPt a ~Iy tmerd approvm by b AdVISOry BoaJd of Osteow-tblc Sp8Ci&bIli aIX1 die Boenlof Truaa-. of tbe Amencan OsfeOl8thac Associa~. A ~~ of my spec:iabty t..rd cenificaee is ."~.

- II8w t-. dec:1arwi a...d elifible by alpeciabcy bc.rd apprav.t by die AdvISory brd of Osleo.-lbic Specialists. VeriflC8bODfnxu my IpeciaJicy tx.rd dial I am tx.rd eblible is alt8Cb.1.

- I bave compIelC a ra~ plVpam in a fomp ~: my ...ufIca~ aIX1 tr8iDIDI are ecceJM8b1e for admis.~ iD 10 &beezamiDabG1lyS~ of die ~ AmeriC8D SJ*:Iabty bid. A letter of my lpecably tx.rd YerifyDI& Ibis ilaUK!Ied.

To be coaaM1er.s a Specialist. die aeaer or pbotocopy DlSt be aaacl-s. If yaar appbcation is for a ~ or professioaal asIOC1abOD.~h~~iD die ~ or UI«~ _who wJII8 10 be ~Mier.s a Specialist DlSt sutxDit the ~ verificabOD.

CAT OFSVC

CODE

CAT OFSVC

CODE

UCAT OFSVC

CODE

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DHMH XXXX.B

L I I

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CATEGORIES OF SER\1CE

CAT OF CAT OF CAT OFSVC SVC SVC

CODE CODE CODE

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CODE

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PROVIDER APPLICATION INSTRUCTIONS

JONAMEBEGIN DATE

LL I I I l~U I I I I_~LLI I I I~LL' III~LI I I I L~L' I I I L~

GROUP MEMBERSHIP INFOR~IATJONPROVIDER. NUMBER

L I , I I I I I I~

L' I , , I I I I~U II I , I I J~U_II I I I I U

I_~UIIIIIII_J L I I I I I I I I_J

(Y/N)='Is YCKlr Group operating. l.DCa1 Heald! ~t Clinic?

(Y/N):615 your grwp operalm, a F~taIX1iDg Clinic?

%1lfy~r JrGUp is affiliated with. Health Care JDSciftltion. please live its name u¥i address:

Db your IfwP saJaried by the institution? -1Y/N)

2Iff ycxsr poup is affiliated with. medicallclXJol. please live its ~ 8J.J .xbas:

~o ycxa W8Dt to emoU as. .RelKieriDg OaIy. practiti~? - (Y/N)

NOTE: All pnctitil)ners in . P m~ be enrolied as Medical Can Program providers.

ALTERNAl1VE ADDRESS INFORMATION

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»YOUR FISCAL YEAR END DATE: LU LUBED DATA

I OF BEDSM# OF BEDSSERVICE T\'PEIntermediate Care (lCF)

Acute lDpAhent (1NP)Skilled Nursing (SNF)

SERVICE nOPEOdJer (OTH)

CbrODJ~ Hospital (CHB)

Mental Retaru-tIOD (M ]

PROVIDER APPLICA 11ON INSTaUC110NS

LABORATORY CLA.5SIF1CA110NS

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If voo woold like information concemiD electronic claims IUtxnissiODS. lease contaCI d1e Svslem lor 81410-767-5863.M OTHER PRAC11CE LOCA nON INFORMA nON

Please eater odler l~tiODS wilen yw lervice Marylalxi MGcal Aslil~ recipieaII. bx:hxle.U InxIP 8ddres1es y~ are cuneadypracticiDI UlXler. IF APPUCABLE.

0UDTEflllllllllllllllllllllllll'11111111111111111111111111111CITY ST ZIP CODEIIIIIIIIIIIIIIIIIIII L1J 111111-11111PHONE: l_liJ - L.LU -I 1 1 I 1 Will yGI accepc REFERRAl.5 at this Ioc~~? U (Y/N)

LICENSE NUMBER 1 I I 1 1 I I I I I UCENSEEXPlRA110NDATE I I I I I I I-~ - --~ - - -- - -

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lllllllllllllllllill LU llllll-lllllPHONE: L_UJ - L.UJ . ( ( ( ( ( Will you 8CC8pt REFERRALS at this location? U (Y/N)

UCENSE NUMBER (I ( ( I I I I I I UCENSE EXPIR.A110N DATE I I I I ( I I

DHMH XXXX.B

)

PROVIDER APPLICATION INSTRUCT1~

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,--i-I",,"""I"II!1 W 111111-1_1111PHONE: LJ.JJ -l.J.JJ .11 , I I Will y- accept REFERRALS al dIis Iocalioa? U (Y/N)

UCENSENUMBER I I I I I I , , , 'UCENSE£XPlRA1l0~DAT£ I I I I I I I--

iml II III I I I I I I I I I I I I I I I I I IIIIIIIIIIIIIJIIIIIIIIIIIIIIIIICITY ST ZIP CODEIIIIIIIIIIIIIIIIIIII LU 111111-11111PHONE: Ll..lJ - L.J..lJ -I I I I I Will y~ 8CCepc REFERRALS arl1us location? U (Y/N)

UCENSE NUMBER I I I I I I I I I IUCENSE EXPIRATION DATE I I I I I I I-

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PHONE: Ll-U -l_l.JJ -I I I I I Ww YCXI accep REFERRALS at dUs IocatiCXl? U (Y/N)

UCENSENUMBER I I I I I I I I I I UCENSEEXPIRA110NDATE I I I I I I I

I. Ille practitioner. Id1niniJlralor or authorized professiOl81 representative of tbis eroup. heRby atrum that this iDfOnMUOD livea by meis true and complete to &be best of my kDow*i,e uMi beljef. ) ~nl8lxi thaI if) or my ,~p aslalari.J by 8 IMJlpilaJ or otherIDSlllUbOD for p8beal care. thaI) or my JfouP will 001 bill die M8ryWd Medical Care Program for dIOse lervl~ for which) or mygroup is l8l8ned.

. - -AlTTHOR1ZED PRACTrrJONU'S. ADMINISTRATOR'S OR AlTTHORJZED PROFESSIONAl. RESPONSIBLE FOR QUAUr\- CARE.

(P~ PriDt or Type)

DATI: SlGNAT\IRE OF PRACTITIONER. ADMINISTRATOR OR AUTHORIZEDPROfESSIONAL RESPONSIBLE FOR QUALITY OF PAn~'T CARE

- - - SlG~A.n,"RE or OWt\"ER liD tk un or. Pblr8KY)

Please return your colnpleled 8pplJC8tiOD 10 PrO!r8ms Systems uKi OperauODS Adm!mstraUODProv_r Master FilesP.o. Box 17030

Ba1limore. MD 21203

, the Provider's duly authorized(-the Provider) by

nIE PROVIDER AG~:1To comply with all of the applicable requirements of the Maryland Medical

Assistance Program (MProgram") as well as any other applicable regulations.ttansmittals and guidelines issued by the Depanment. The provider acknowledgeshis responsibility to become familiar with those requirements. The provider isadvised that the applicable regulations may differ significantly from those of other

third-party payer programs.

A.

B.

QIi~ina1 records must be made available upon request during onsite visits

by Department personnel.1

CQ~ies of records are to be forwarded upon written request of the

Depanment.2

To protect the confidentiality of all recipient information. including names.addresses. m~ca1 servi~ provjded and medical data about the recipient. such asdiagnoses and past history of disease and disability. Such information may berel~sed to a third piny other than another treating provider only upon me consentof the recipient or the Department. except as otherwise pennitted by State orfederal law or regulation. or other legal process.

c.

To provide services without regard to race. creed. color. age. sex. national origin.marital status. or physical or mental handicap.

D.

E. To not knowingly employ, or contract with a person, panncrsbip. or corporationwhich has been disqualified from the Program to provide or supply services toMedical Assisrance recipients unless prior written approval has been received fromthe Dcpanment.

F. To accept as payment in full the amount paid by the Program for the servicererx1ered aOO not seek additional payment from the recipient. If the Programdenies payment or requests repayment on the basis that an otherwise covercdservice was not medically necessary or was not preauthorized if required byregulation, the provider agrees not to seek payment for that service from therecipient.

G. That if the recipient has insurance or other coverage or if any other person isooligated, either legally or contractually, to pay for, or to reimburse the recipientfor services covered by the Program, to seek payment from that source first. Ifpayment is made by both the Program and the insurance or other source, theprovider shall refum to the DepanJnent, within W days of receipt, the amount paidby the Program or the insurance or other source, whichever is less.

H. To accept reSJX)nsibility for the accuracy of all claims submitted to the Program orwhich have been submitted to the ProgJam on his behalf using the provider numberissued in his name.

To attest that aU claims submitted uooer his provider number shall be for medicallynecessary services, actually provided as described in the claim. The provideracknowledges that the submission of false or fraudulent claims could result incriminal prosecution and civil and administrative sanctions, including expulsionfrom the Program, under relevant law or regulation.

That if the provider is a physician. he will. upon request. submit to the Programthe name and applicable licensure for each physician extender in his employ andfor whom the provider will submit claims or has submitted claims for servicesrendered to recipientS. The physician is responsible for knowing and complyingwith the applicable regulations of It. Program defining who is eligible to act as aphysician extender under the Program, and to provide supervision as required by

K.

the Program.That in the case of a group provider. the individuaJ provider rendering the serviceshall include on the claim his own provider number as well as the group providernumber.

L. To furnish the Depanment, within 3S days of the Department's request, full andcomplete information about:

1 The ownership of any subcontractor with whom the provider has hadbusiness transactions totaling more than $25.000 during the l2-monthperiod ending on the date of the request: and

2. Any significant business transaction between the provider and any wholly-owned supplier. or betw~n the provider and any subco!i:i3ctor. during the5 year period ending on the date of the request.

3. Any ownership interest exceeding 5 % held by the provider in any otherMedical Assistance provider.

M. That. upon request. and before the Depanment enters into or renews a provideragreement. the provider agrees to disclose the identity of any person who:

1 Has an ownership or control interest in the provider, or is an agent ormanaging employee of the provider; and

2. Has been convicted of a criminal offense related to that person'sinvolvement in the Medicaid or Medicare programs.

n THE DEPARTMENT AGREES

A. To pay the provider for medically necessary services provided to recipients andcovered by the Maryland Medical Assistance Program in accordance with allProgram regulations and fee schedules as incorporated by reference in the Code ofMaryland Regulations.

B To provide notice of changes in Program regulations through publication in theM3~lanrl R~~i(t~r in accordance with its publication schedule.

III. THE DEPARTMENT A."D PROVIDER MUTUALLY AGREE:

~ ,jA. That except as specifically provided otherwise in applicable law and regulations.

either party may terminate this agreement by giving thirty (30) days notice inwriting to the other pany. The Provider shall notify recipientS, before renderingadditional services, that he no longer honors Medical Assistance cards.

B. That the effective date of this agreement shaIl be .DHMH will determine the effective date based on verification of the infonnationcontained in the provider application. This agreement shall remain in effect untilsuch time as it is terminated by either pany pursuant to the terms of this

- agreement. Tennination of this agreement shal1 not discharge the obligations ofthe Provider with respect to services or items furnished prior to tennination.including retention of records and restitution of overpayments.

c. That no employee of the Stale of Maryland or any department, commission, agencyor branch thereof, whose duties as such employee include matters relating to oraffeCting the subject matter of this contract shall, while such employee, become orbe an employee of the party or parnes hereby contracting with said State ofMaryland or any department, commission, agency or branch thereof without thewritten permission of the Department; and

D.

JProvider Signature Date

That this agreement shall not be transferrable or assi~ab)~. . -.

c;--J,,~ 2 , ->. tion Oa&t

.-, ,.i J,- -~ISI&Dt At~rDey ~Deral DatfProvider Name (Typed or Printed)

Provider Address (Typed or Printed)

Provider Number

STATE OF MAR\'LANDDEPARTMENT OF IlEAL11f AND MENTAL HYGIENE

MEDICAL CARE PROG~IPROVIDER APPUCA110N FORAf

GROUP ADDENDUM

ST ATE OF MAR\'LANDDEPARTMENT OF REALm AND ~"AL HYGIENE

MEDICAL CARE: PROG~fPROVIDER APPUCATION FODf n

PRA CTITI 0 NER ADDENDUM

If yua ue salaried u . staff M.D.. D.O.. D.D.S.. or D.M.D.. are y~ salaried for ~t care? Ya _No -

STATE OF MAR\PLANDDEPARTM~" OF REALm A~'D MENTAL HYGIENE

MEDICAL CARE PROGRAMPROVIDER APPLICA nON FORM

INSTITUTION ADDENDUM

Slate of MarylalKi . ~~I of HaIth aDd MCDIa1 HYI&~Medical AslaslaDCc Pro,ram

PROVIDER OWNERSHIP AND CONTROL DISCLOSURE FORM

NI~ r;rYou~cdICII Scrv.cc or ~~ Prv;;dcr O-~.J ;;nllUlcd on yo-;;r Ip:J;bcMnl

(Appucab1~ to all Provider of Items or servICes I excepl for ilxilvKiuaI prachbooen or ,roups of praCbbO~ ::

PurluaDI to 42 CFR §4SS. 100 et. leq.. die disclosure of dte foJloWIDI u a ~Ir.t fM)nJOU of the Maryiald Medical.~~I~~"~ Provder "~_"'ADCXI n.rwfore.,-.e aDS-r the toJJowlDI queabODl aid IIID cbJs docwnenl affll1DlD~ thaIthis iDfolmalioa is true aid ~~I@t~ aid reum Wldl y~r appbCAbOD.

N8IMo lay penou who. WIth rap-:llo die Title XIX Provider J:

I . II IJ1 officer or dllKaor

A

2. u.~~r

3. bas. dUKt or uxiUKt OWMrsWp !DIenst. of oS ~ or ~R

bas . combIaa~ of dua:t 8I.t ahrect OWKntuplnterats ecpaal to S Ic or DKJR In die PruvKler

5. II 8U OWDe1' (m wbole or m~) of 8U Ul&emr of 5~ or ~re maay monple. deed of crusl. note. or otber

obIJpuon secured (m wl»Je or m J8I1) by dw ProvKier or aU ii--"'; or useU if hI mlereSl ecp&a1s .1 leu I5 ~ of !be vaJue of !be ii-~" f or useu of !be Provider

Bo- --

WIth respect to auy lutx:oarraccor ID wbacb d8I Tide XIX Prov~r bas. directly or iIxii~tly. au ~rshlp or

ccx-.oI-*r81 o( 5 ~ or D)ft. ~ aay person who (alls within A. 1-5 above. as appli«i to tI~ IUtx:ontractDr 8Ixilpecify which o( the atM)ve cate,ones be faUs WIthin

c If any fJenOD ~ m ~ to Pan A. 1-5. atxJve. bas uy of die Rlabomblps d~ribed in !bat Pan WIth

aD) T.tIc XIX PlOY., of ~ or aervica ~ dIan the appbc:ani. or WIth any entJry that does _I ,.nacapete

as MaiICaXi tilt IS r-.w.s k) dascbe ~ OWMrship aD! coauol iDformabOD because of ,.nici,.bOD ID uyof tbe pro!fams established UJder Tide V. XVID. or XX of the Soc..1 Scunry Act. Slale the Dame of die

pcr~o". tile Dame of the other ProvKter. UK! the IMIUR of tile relationship.

2. If 11~ answer 10 Pan C. 1. atM>ve. COD18lm &be ~ of DX)re 111811 tWo penom. stale whel1~r MY of those so

~ned are related to each olber as S}QISe. ,-ral. cbikl or Ilb!mc.

.f

Name aDY perIOD who bas beea CoDv1C*) o( a ~I offeue R18181 10 bas IDvolvcmeDl WtW any p!'Ol~

~ \DieT Tide xvID. XIX. or XX O(b Scx:IaJ Secunly Acl. and who. WIW R!ard 10 Ihe Title XD.: Provider.

(ails WIUun die proVlSlOUS o( A.I.oS. above. or IS an a,enl or 8 fn8aa!1D1 employee Ian uxtlvldual. 1DC1udID, 8

,_ral maaa,er. ~Iralor aIKf dll'8Clor. wl»o exercISes operalloaal or man&!enal conlrol or ~'bo directly or

adireclly coIxiUCLS !he d8Y-lo-day operaUOD.S J

D.

n

I hereby affirm Ibal dill mforma~ &I tNe aIXi complele 10 die beSI of DIY knowled,e 8Ixl belief. aIXi thaI Ule

rapIeItaf a~ wiD be UFIiaI81as c-,. «aJI. I further certlfy chat uP'D speelfic request by the SecRtary

of die ~ of H.Jd1 . ~bOD uxI Welfare. or d. Mary1uxl o.~ of Health uxI MeDtal Hy!ieue.full uxI complete mfOnD8hon will be suppliaf Wld11n 35 days of the date of the requal. conccnuag:

A. b o~ of 8I1Y sub:GJtrKfor Wld1 which die TItle XIX ProvKler bas 1181.1. dunDI dJe PftVtOUS 12 moDd1S

~...s transactions UI an aSl1e,ate amount ID excess of S25.000.00 aOO

B. aay lipificanl b1siness transaeuons', ~mn! dUrU1! &he 5-ycar pcncxi elxilD! on &he dale of such requeSl.

betW.u the Prvvider -Ix! aay wholly-own..d IUppller' or any sutx:0nU'8clor

DATE AUTHORIZED SIGNATURE

POsmON

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DHMH .4126G