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PROVIDER AGREEMENT BILLING PROVIDER ENROLLMENT APPLICATION SCHEDULE C
State Form 51453 (R/1-08) / Part of State Publication 286

Indiana State Department of Health

Ownership Information 1. How is this provider entity legally organized and structured?
For Profit Corporation Not-for-Profit Corporation Partnership Government Owned Sole Proprietorship

Check the entity type that best describes the structure of the enrolling provider entity. Please check only one item.

2.

Is this entity chain affiliated?

If yes, the information regarding the chain must be included in Item 4 below.
Yes No

3.

Is this entity operated by a management company, or leased in whole or part by another Organization?
Yes No

4.

List all owners and officers of the business entity

List below the Name, Title, Social Security Number, and Address of each Officer, owner, and / or trustee of the provider entity, and the Name, Tax ID (TIN), and Address of any organization, corporation, or entity having direct or indirect ownership or controlling interest in the provider entity. Attach additional pages as necessary to list all officers, owners, management and ownership entities.

______________________________ Name ______________________________ Relationship or Title

____________________ _________________________________________ Tax ID Number Address _________________________________________ City, State, ZIP + 4

_____________________________ Name ______________________________ Relationship or Title

____________________ _________________________________________ Tax ID Number Address _________________________________________ City, State, ZIP + 4

_____________________________ Name ______________________________ Relationship or Title

____________________ _________________________________________ Tax ID Number Address _________________________________________ City, State, ZIP + 4

ISDH ­ Provider Relations Provider Agreement Schedule C

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5.

Has there been a change in ownership or control within the past year, or is a change of ownership anticipated?

If yes, you must submit the enclosed CHANGE OF OWNERSHIP ADDENDUM form for the current provider entity, and a new application for the new ownership entity. Yes No

6.

Has there been a past bankruptcy or do you anticipate filing for bankruptcy within a year?
Yes No If yes, when? ___________________________

7.

Background Information

Has any agent, managing employee, or owner of the provider entity been excluded from or convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, Title XX or ISDH program since the inception of those programs? Yes No

If yes, state below the Name, SSN, and position within the provider entity: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________

ISDH ­ Provider Relations Provider Agreement Schedule C

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