AgdaPkt 2018-01-22 Joint SA PFA - Laserfiche WebLink

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6.1.C. - Page 65 Name Address SSN/TIN Date of Birth Type of Interest (a -f above) PART 5: SUBCONTRACTOR RELATIONSHIPS List any persons named in Part 2 that is related to a person listed in Part 4 as spouse, parent, child or sibling. You only have to list each relationship pair once. For example, if you've listed John Smith in Part 2 and Mary Smith in Part 4, just list John Smith related to Mary Smith as husband. You don't need to also list Mary Smith related to John Smith as wife. II Name Related to: PART 6: OTHER DISCLOSING ENTITIES Relationship "Other Disclosing Entity" means: (a) an organization, agency or business that is a Medicaid provider or a Medicaid fiscal agent, OR (b) any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare, OR (c) any Medicare intermediary or carrier, OR (d) any other entity (other than an individual practitioner or group or practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Social Security Act. List the information below for any person listed in Part 2 who is also a "Person With an Ownership or Control Interest" (as defined in Part 2) for any Other Disclosing Entity. IIPerson or Corp. Name (from Part 2) PART 7: MANAGING EMPLOYEES Other Disclosing Entity Name and Address "Managing Employee" means a general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-to-day operation of the Entity. List the information below for all Managing Employees of the Entity. Revised 3/9/2015 Page 4 of 5 REV: 01-17-18 RL ATTY/AGR/2018.012/COUNTY OF SAN MATEO