Letter to CMS - Medicaid Managed Care Policies - Agency for ...

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APPLICATION ITEM
d. Disclosure of Ownership and Control Interest Statement, CMS-
1513.
e. Letter disclosing information on the applicant’s significant
business transactions with any party that has any interest in the
profits of the applicant;
f. Letter attesting no officer, director, or agent of the applicant is
an employee of the State of Florida, or any of its agencies; and
g. Letter attesting there is no action or suit filed or any claim
made against the applicant by any subcontractor, vendor, or
other party that results in litigation for disputes or damages
exceeding the amount of $50,000.
G. Forms
Enrollment Projection
Background Screening Manager List
HSD Internal Working Document
MCO APPLICATION REVIEW CHECKLIST FOR Phase I
INSTRUCTIONS (if applicable)
Review with B.10. Ownership and Control Interest.
Confirm for PSN, providers hold majority
percentage of applicant ownership.
Confirm letter meets the disclosure requirements.
Confirm letter meets the attestation requirements.
Confirm letter meets the attestation requirements.
LOCATION IN
APPLICATION
(Binder, Tab & Page #)
Date Deficiencies
identified/Date
Deficiencies resolved
Revisions as of 1/23/2012 Page 19 of 19
INITIALS &
DATE
COMPLETED