Lab 1513 Form PDF Details

In an effort to maintain transparency and uphold the integrity of health services, the State of California—Health and Human Services Agency California Department of Public Health necessitates the completion of the Disclosure of Ownership and Control Interest Statement, also known as the Lab 1513 form. This comprehensive document plays a critical role in the licensing and regulation of facilities within the state, requiring entities to disclose detailed information including, but not limited to, ownership details, any indirect or direct control interests, the identification of individuals or organizations with significant stakes in the entity that have been convicted of criminal offenses related to healthcare programs and any potential conflicts of interest. Sections of the form address specific queries regarding changes in ownership or control, affiliation with chains, and operational dynamics such as management by external companies. Key elements such as identifying information about the entity, its operational structure, affiliation status, and any changes in key administrative positions are methodically scrutinized to ensure compliance with federal and state laws. Failure to accurately complete the Lab 1513 form can have serious legal consequences, underscoring the importance of full disclosure to avoid the risk of prosecution or the termination of agreements with state agencies.

QuestionAnswer
Form NameLab 1513 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfalse, image disclosure of ownership form for nemt, EINs, proprietorship

Form Preview Example

State of California—Health and Human Services Agency

 

 

 

California Department of Public Health

DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I. Identifying Information

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of entity

 

D/B/A

 

 

 

 

 

 

 

 

 

 

Address (number, street)

 

 

City

 

State

ZIP code

 

 

 

 

 

 

CLIA number

Taxpayer ID number (EIN)

 

Telephone number

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

II.Answer the following questions by checking “Yes” or “No.” If any of the questions are answered “Yes,” list names and addresses of individuals or corporations under “Remarks” on page 2. Identify each item number to be continued.

YES NO

A.Are there any individuals or organizations having a direct or indirect ownership or control interest of five percent or more in the institution, organizations, or agency that have been convicted of a criminal offense related to the involvement of such persons or organizations in any of the programs established

by Titles XVIII, XIX, or XX?

❒ ❒

B.Are there any directors, officers, agents, or managing employees of the institution, agency, or organization who have ever been convicted of a criminal offense related to their involvement in such

programs established by Titles XVIII, XIX, or XX?

❒ ❒

C.Are there any individuals currently employed by the institution, agency, or organization in a managerial, accounting, auditing, or similar capacity who were employed by the institution’s, organization’s, or

agency’s fiscal intermediary or carrier within the previous 12 months? (Title XVIII providers only)

❒ ❒

III.A. List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. (See instructions for definition of ownership and controlling interest.) List any additional names and addresses under “Remarks” on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under “Remarks.”

NAME

ADDRESS

EIN

B. Type of entity:

Sole proprietorship

Partnership

Corporation

Unincorporated Associations Other (specify) ______________________

C.If the disclosing entity is a corporation, list names, addresses of the directors, and EINs for corporations under “Remarks.”

D.Are any owners of the disclosing entity also owners of other Medicare/Medicaid facilities? (Example: sole proprietor, partnership, or members of Board of Directors) If yes, list names, addresses

of individuals, and provider numbers

❒ ❒

NAME

ADDRESS

PROVIDER NUMBER

LAB 1513 (7/07)

 

 

YES

NO

IV. A.

Has there been a change in ownership or control within the last year?

 

If yes, give date. ___________________________________________

 

 

B. Do you anticipate any change of ownership or control within the year?

 

If yes, when? ______________________________________________

 

 

C. Do you anticipate filing for bankruptcy within the year?

 

If yes, when? ______________________________________________

 

 

V. Is the facility operated by a management company or leased in whole or part by another organization?

If yes, give date of change in operations. ___________________________

 

 

VI. Has there been a change in Administrator, Director of Nursing, or Medical Director within the last year?

VII. A.

Is this facility chain affiliated?

 

(If yes, list name, address of corporation, and EIN.)

 

 

Name

EIN

Address (number, name)

City

State

ZIP code

B.If the answer to question VII.A. is NO, was the facility ever affiliated with a chain? (If yes, list name, address of corporation, and EIN.)

Name

EIN

Address (number, name)

City

State

ZIP code

Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the information requested may result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the state agency or the secretary, as appropriate.

Name of authorized representative (typed)

Title

Signature

Date

Remarks

LAB 1513 (7/07)

How to Edit Lab 1513 Form Online for Free

image disclosure of ownership form for nemt can be filled out with ease. Simply try FormsPal PDF tool to do the job right away. The tool is constantly upgraded by our team, receiving awesome features and growing to be better. To get the ball rolling, consider these easy steps:

Step 1: Access the PDF form in our tool by clicking the "Get Form Button" above on this webpage.

Step 2: When you launch the PDF editor, you'll see the form prepared to be completed. Apart from filling in different blank fields, you can also do various other things with the form, namely writing any text, modifying the original textual content, adding graphics, placing your signature to the document, and a lot more.

This form will require you to type in some specific details; in order to ensure accuracy, remember to take heed of the next tips:

1. While filling in the image disclosure of ownership form for nemt, make sure to complete all needed blank fields within its corresponding part. It will help to speed up the work, enabling your details to be processed efficiently and correctly.

Part no. 1 of filling out disclosure of ownership form texas clia

2. Once your current task is complete, take the next step – fill out all of these fields - NAME, ADDRESS, EIN, Type of entity, Sole proprietorship, Unincorporated Associations, Partnership Other specify, Corporation, If the disclosing entity is a, Are any owners of the disclosing, and provider numbers, NAME, ADDRESS, and PROVIDER NUMBER with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Step number 2 of filling in disclosure of ownership form texas clia

3. This next portion is related to LAB - complete all of these blank fields.

LAB, LAB, and LAB of disclosure of ownership form texas clia

4. The next section needs your attention in the following areas: Has there been a change in, YES NO, Do you anticipate any change of, Do you anticipate filing for, Is the facility operated by a, Has there been a change in, VII, Is this facility chain affiliated, Name, EIN, Address number name, City, State, ZIP code, and If the answer to question VIIA is. Be sure that you type in all needed details to move further.

Simple tips to prepare disclosure of ownership form texas clia portion 4

As to If the answer to question VIIA is and Do you anticipate any change of, be sure that you do everything properly here. These are the most significant ones in the PDF.

5. Finally, the following last part is precisely what you need to finish before submitting the PDF. The fields in question include the next: Whoever knowingly and willfully, Name of authorized representative, Signature, Remarks, Title, and Date.

Filling out part 5 of disclosure of ownership form texas clia

Step 3: When you've looked once more at the information in the file's blanks, click on "Done" to finalize your form. Join FormsPal right now and immediately get access to image disclosure of ownership form for nemt, all set for download. All adjustments made by you are kept , making it possible to modify the document further if needed. FormsPal guarantees your information confidentiality by using a secure system that in no way saves or distributes any kind of private information typed in. Be assured knowing your files are kept safe any time you use our services!