ࡱ> ehd Ebjbj$$ 7bF|F|0   8DL (t(<<<+++>(@(@(@(@(@(@($G*,d(++d(<<y( d<<>( >( VV&@'<*g& *((0(&x--'-'++ +++++d(d( +++(+lp-+++++++++ : DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT (CHOW) I. NEW Identifying Information Name of Entity D/B/A CLIA ID No. Tax Identification No. Street Address City, County, State Zip Code Telephone Number Facsimile Number New Owners Name Medicare Provider No.Medicaid Provider No. Fiscal Year End Date  II. Previous Identifying Information Name of Entity D/B/A CLIA ID No. Tax Identification No. Old Owners Name Street AddressCity, County, State Zip Code  III. What is the date of the change in ownership or control? _____________________________________ IV. (a) List names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. List any additional names and addresses under "Remarks" on page 2. If more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks or as an attachment labeled IV a. NameEINAddress (b) Type of Entity:  FORMCHECKBOX  Sole Proprietorship  FORMCHECKBOX  Partnership  FORMCHECKBOX  Corporation  FORMCHECKBOX  Unincorporated Associations  FORMCHECKBOX  Other (Specify)_________________________ (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks or as an attachment labeled IV c. Check appropriate box for each of the following questions: (d) Are any owners of the disclosing entity also owners or affiliates of other CLIA certified facilities? If yes, list names, addresses of individuals and provider numbers below or as an attachment labeled IV d.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name Address_ CLIA ID Number__ ____ V. Is this facility operated by a management company, or leased in whole or part by another organization?  FORMCHECKBOX  Yes  FORMCHECKBOX  No VI. a) Has there been a change in Laboratory Director within the last year?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Current Director: b) Is the Laboratory Director of the disclosing entity also the Laboratory Director of other CLIA certified facilities? If yes, list names and CLIA ID numbers below or as an attachment labeled V b.  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name______________________________________________________ CLIA ID #___________________ Name______________________________________________________ CLIA ID #___________________ Name______________________________________________________ CLIA ID #___________________ VII. (a) Is this facility chain affiliated? (If yes, list name, address of Corporation, and EIN below and as attachment labeled VII a if needed.) Name and address EIN # (TAX ID)  NOTE: Whoever knowingly and willfully makes or causes to be made a false statement or representation of this statement, may be prosecuted under applicable federal or state laws. In addition, knowingly and willfully failing to fully and accurately disclose the information required by result in denial of a request to participate or where the entity already participates, a termination of its agreement or contract with the state agency or the secretary, as appropriate. 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