Individual Provider Enrollment (Ownership) Page

You are here: Providers > Enrollment > Provider Enrollment Pages > Individual Provider Enrollment (Ownership) Page

You use the Ownership page to add or edit an individual provider's ownership information to the enrollment application.

Ownership- Section 7 Fields

Field	Description
Ownership Fields
1. Have you ever had ownership in any organization that has billed, or is currently billing Medicare or ND Program services?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit your ownership information.
To add new ownership information, click Add Ownership. Existing ownership information, if any, is listed in a table. To edit, in the Ownership table, click the appropriate table row. After changing or adding new ownership information, on the Ownership action bar, click Save.
Organization’s Legal Business Name	Organization's legal business name as it appears in IRS forms.
Effective Date	Date when ownership became effective. Format: MM/DD/YYYY, or click the calendar to select a date.
End Date	Date when ownership ends. Format: MM/DD/YYYY, or click the calendar to select a date.
Address	Physical street address of organization.
City	City where the organization is located.
State	State where the organization is located.
Zip	Zip code and extension where the organization is located.
EIN #	Organization's employer identification number.
Please enter your NPI and/or Medicaid numbers.	Select to indicate if you have a current Medicare and/or Medicaid number.
NPI #	The organization's National Provider ID number.
Current Medicare Number	Organization's current Medicare number.
Current ND Provider #	Organization's current Medicaid number.
Managing/Directing Fields
2. Have you ever managed or directed any organization that has billed or is currently billing Medicare or ND Medicaid Program services?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to complete information for each organization the owner has managed or directed in the last 10 years.
To add new managing/directing information, click Add Managing/Directing Information. Existing managing/directing information, if any, is listed in a table. To edit, in the Managing/Directing Information table, click the appropriate row. After changing or adding information, on the Managing/Directing Information action bar, click Save.
Organization’s Legal Business Name	The legal business name of the organization.
Effective Date	Date when ownership became effective. Format: MM/DD/YYYY, or click the calendar to select a date.
End Date	Date when ownership ends. Format: MM/DD/YYYY, or click the calendar to select a date.
Address	Physical street address of organization.
City	City where the organization is located.
State	State where the organization is located. Default: ND
Zip	Zip code and extension where the organization is located.
EIN #	Organization's employer identification number.
Please enter your NPI and/or Medicaid numbers.	Select to indicate if you have a current Medicare and/or Medicaid number.
NPI #	The organization's National Provider ID number.
Medicare #	Organization's Medicare number.
Current ND Medicaid #	Organization's current Medicaid number.
Subcontractor Information Fields
3. Do you have an ownership interest of 5% or greater in a subcontractor for your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients.)	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit subcontractor information.
To add new subcontractor information, click Add Subcontractor. Existing subcontractor information, if any, is listed in a table. To edit, in the Subcontractor table, click the appropriate table row. After changing or adding information, on the Subcontractor Information action bar, click Save.
Subcontractor Name	Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients.
Address	Physical street address of the subcontractor providing medical care to your patients.
City	City where the subcontractor is located.
State	State where the subcontractor is located.
Zip	Zip code and extension where the subcontractor is located.
Subcontractor Relative Fields
4. Do any of the members of your immediate family (spouse, parent, child, sibling) have ownership of 5% or greater in a subcontractor to your business or practice?	Select Yes or No to indicate your answer. If you select Yes, then additional fields are displayed for you to add or edit family information.
To add new family information, click Add Relative. Existing subcontractor information, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding information, on the Relative Information action bar, click Save.
Last Name	Last name of the relative who has ownership in the subcontractor business or practice.
First Name	First name of the relative who has ownership in the subcontractor business or practice.
MI	Middle initial of the relative who has ownership in the subcontractor business or practice.
Suffix	Suffix of the relative who has ownership in the subcontractor business or practice.
Relationship	Relationship of relative to the owner of the subcontractor business or practice.
Subcontractor Name	Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients that is associated with the relative.
Address	Physical street address of the subcontractor associated with the relative.
City	City where the subcontractor associated with the relative is located.
State	State where the subcontractor associated with the relative is located.
Zip	Zip code and extension where the subcontractor associated with the relative is located.

Field

Description

Ownership Fields

1. Have you ever had ownership in any organization that has billed, or is currently billing Medicare or ND Program services?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit your ownership information.

To add new ownership information, click Add Ownership. Existing ownership information, if any, is listed in a table. To edit, in the Ownership table, click the appropriate table row. After changing or adding new ownership information, on the Ownership action bar, click Save.

Organization’s Legal Business Name

Organization's legal business name as it appears in IRS forms.

Effective Date

Date when ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select a date.

End Date

Date when ownership ends.

Format: MM/DD/YYYY, or click the calendar to select a date.

Address

Physical street address of organization.

City

City where the organization is located.

State

State where the organization is located.

Zip

Zip code and extension where the organization is located.

EIN #

Organization's employer identification number.

Please enter your NPI and/or Medicaid numbers.

Select to indicate if you have a current Medicare and/or Medicaid number.

NPI #

The organization's National Provider ID number.

Current Medicare Number

Organization's current Medicare number.

Current ND Provider #

Organization's current Medicaid number.

Managing/Directing Fields

2. Have you ever managed or directed any organization that has billed or is currently billing Medicare or ND Medicaid Program services?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to complete information for each organization the owner has managed or directed in the last 10 years.

To add new managing/directing information, click Add Managing/Directing Information. Existing managing/directing information, if any, is listed in a table. To edit, in the Managing/Directing Information table, click the appropriate row. After changing or adding information, on the Managing/Directing Information action bar, click Save.

Organization’s Legal Business Name

The legal business name of the organization.

Effective Date

Date when ownership became effective.

Format: MM/DD/YYYY, or click the calendar to select a date.

End Date

Date when ownership ends.

Format: MM/DD/YYYY, or click the calendar to select a date.

Address

Physical street address of organization.

City

City where the organization is located.

State

State where the organization is located.

Default: ND

Zip

Zip code and extension where the organization is located.

EIN #

Organization's employer identification number.

Please enter your NPI and/or Medicaid numbers.

Select to indicate if you have a current Medicare and/or Medicaid number.

NPI #

The organization's National Provider ID number.

Medicare #

Organization's Medicare number.

Current ND Medicaid #

Organization's current Medicaid number.

Subcontractor Information Fields

3. Do you have an ownership interest of 5% or greater in a subcontractor for your business or practice? (A subcontractor is an individual, agency, or organization to which an applicant/provider has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients.)

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit subcontractor information.

To add new subcontractor information, click Add Subcontractor. Existing subcontractor information, if any, is listed in a table. To edit, in the Subcontractor table, click the appropriate table row. After changing or adding information, on the Subcontractor Information action bar, click Save.

Subcontractor Name

Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients.

Address

Physical street address of the subcontractor providing medical care to your patients.

City

City where the subcontractor is located.

State

State where the subcontractor is located.

Zip

Zip code and extension where the subcontractor is located.

Subcontractor Relative Fields

4. Do any of the members of your immediate family (spouse, parent, child, sibling) have ownership of 5% or greater in a subcontractor to your business or practice?

Select Yes or No to indicate your answer.

If you select Yes, then additional fields are displayed for you to add or edit family information.

To add new family information, click Add Relative. Existing subcontractor information, if any, is listed in a table. To edit, in the Relative table, click the appropriate table row. After changing or adding information, on the Relative Information action bar, click Save.

Last Name

Last name of the relative who has ownership in the subcontractor business or practice.

First Name

First name of the relative who has ownership in the subcontractor business or practice.

Middle initial of the relative who has ownership in the subcontractor business or practice.

Suffix

Suffix of the relative who has ownership in the subcontractor business or practice.

Relationship

Relationship of relative to the owner of the subcontractor business or practice.

Subcontractor Name

Name of the individual, agency, or organization to which you have contracted or delegated some of your management functions or responsibilities of providing medical care to your patients that is associated with the relative.

Address

Physical street address of the subcontractor associated with the relative.

City

City where the subcontractor associated with the relative is located.

State

State where the subcontractor associated with the relative is located.

Zip

Zip code and extension where the subcontractor associated with the relative is located.