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COUNTYOFSAN MATEO <br />HEALTH SYSTEM <br />DATE <br />PROVIDER NAME <br />ADDRESS <br />Dear Provider, <br />Step 6.1.C. - Page 55 <br />Director <br />Behavioral Health <br />& Recovery Services <br />225 37th Avenue <br />San Mateo, CA 94403 <br />www.s€nchealth.org <br />www.facebook.com/smchealth <br />The County of San Mateo is required by Federal statute to request the disclosure of certain <br />information from our contracted providers. As you may be aware, under the Social Security <br />Act; as specified in 42 CFR 455.104 through 455.106 and sections 1124, 1126, 1902(a)(38), <br />1903(i)(2), and 1903(n); providers that deliver MediCal billable services are required to <br />disclose information about their organization related to ownership and control. <br />The information needed is the following: <br />a) Disclosure by providers and fiscal agents of ownership and control information; and <br />b) Disclosure of information on a provider's owners and other persons convicted of <br />criminal offenses against Medicare, MediCal, or the title services program. <br />Agencies are required to provide the disclosure information annually to the County. To bring <br />our files up-to-date, we have created the attached form and request that you complete it and <br />return it to us as soon as possible. If there is anything else listed under 42 CFR that you <br />need to disclose that is not covered on the form, please attach a separate page with the <br />pertinent information. <br />To receive more information about this regulation you may go to the following website: <br />httiD://www. ecfr.aov/cai-bin/text-idx?rQn=d iv6&node=42:4.0.1.1.13.2. <br />We appreciate your cooperation in our efforts to comply with this federal regulation. <br />Sincerely, <br />Susann Reed <br />Contract Manager <br />Behavioral Health <br />REV: 01-17-18 RL <br />& Recovery Services <br />ATTY/AGR/2018.012/COUNTY OF SAN MATEO <br />