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6.1.C. - Page 62 BHRS FORM 700- Provider or Fiscal Agent Disclosure of Ownership and Control Statement PRIVACY ACT STATEMENT: THIS PROVIDES INFORMATION AS REQUIRED BY THE PRIVACYACT OF 1974. The primary use of the Disclosure of Ownership and Controlling Interest Form is to meet federal requirements for the screening of entities wishing to participate in the Medicaid program. Accurate completion of this form is a requirement of receiving or renewing a San Mateo County Behavioral Health & Recovery Services (BHRS) provider agreement and receiving reimbursement from any BHRS program. GENERAL INSTRUCTIONS Please answer all questions as of the current date. If additional space is needed, please attach additional sheets and reference the item number that you're continuing on another sheet. Please read the definitions in each section carefully to ensure correct completion of this form. More detailed information can be found in the Code of Federal Regulations, Title 42, Subpart B — Disclosure of Information by Providers and Fiscal Agents, Sections 455.100 through 455.106. Throughout this document, "Entity" means the organization, institution, business, or agency that is requesting a BHRS provider agreement in the application of which this Disclosure is a part. The "Entity" may also be a fiscal agent or managed care organization. Government -Owned Entities: If the Entity is owned by a unit of government, for example, a state agency or university or college, county health department, or public school, only Part 1 of this disclosure must be completed. All other entities, non-profit or for-profit, must complete all parts of this form. SOCIAL SECURITY NUMBERS BHRS understands that individuals and entities may have concerns about supplying Social Security numbers (SSNs). Collection of SSNs is required by federal regulations as a critical part of the Medicaid provider screening process to prevent fraud and misuse of taxpayer funds. SSNs are handled by a limited number of enrollment staff who are trained to keep the information confidential. Our treatment of SSNs is akin to our treatment of member and provider identification numbers which are not disclosed to the public. BHRS's computer system is highly secure and meets HIPAA requirements for the handling of personal health information. BHRS conducts regular security tests and audits of the system. In addition, only a limited number of BHRS staff can view SSNs in the system. Failure to submit Social Security numbers means that BHRS must decline to contract with the Entity and/or terminate existing contracts. PART 1: ENTITY INFORMATION (a) Name of Entity: (b) DBA Name if any: (c) Federal Tax Identification Number (TIN) OR: (d) Check the type that best describes the structure of the Entity. Check only one box. ❑ For -Profit Corporation ❑ Non -Profit Corporation ❑ Partnership ❑ Government Owned ❑ LLC Revised 3/9/2015 Page 1 of 5 REV: 01-17-18 RL ATTY/AGR/2018.012/COUNTY OF SAN MATEO