Disclosure Certification

In accordance with the New York State Department of Health Standard Clauses for Managed Care Provider/IPA Contracts section B(9)(l), providers are required to have an officer, director or partner of the Provider execute the following certification within 5 days of executing a new agreement with a Medicaid Managed Care Organization (MCO). The MCO must retain this document with the applicable contract for validation during operational surveys.

Questions regarding this certification can be directed to BMCCSProgInt@health.ny.gov

Section A: Participating Provider Information

Section B: Officer, Director or Partner Information (if different from above)

Section C: Managed Care Organization(s)

Name of the Managed Care Organization the Participating Provider has an agreement with to provide services to Medicaid beneficiaries:

Section D: Questions

In order to complete the Participating Provider Owner/Manager Disclosure Certification form, you must certify each of the following statements:

The person signing below, declares, affirms and certifies (hereinafter certification) that the information entered as part of this form is true and that:

Section E: Certification

IMPORTANT: Making a false statement in this certification may subject you to criminal prosecution for a misdemeanor or felony under the New York State Penal Law.

The person signing below, declares, affirms and certifies (hereinafter certification) that the information entered as part of this form is true and that:

1. he/she is the certifying official/provider whose name and contact information appears above;

2. the certifying official/provider has undertaken due diligence and conducted all reasonable inquiry prior to making any of the statements in this certification and has sufficient knowledge to complete this form; and

3. the certifying official/provider acknowledges that this certification is being made in order to comply with the requirements outlined in the questions answered above.