Medicaid Disclosure of Ownership Form: A Worksheet for NEMT Owners Before You Apply

Every state Medicaid agency asks the same core questions about who owns and runs your company, because federal rules in 42 CFR part 455 require it to. Health plans and brokers ask them again on their own forms, in their own words. When one form lists your spouse as an owner and another leaves them off, one of those disclosures is inaccurate, and an inaccurate disclosure alone can stop an enrollment. Fill in this worksheet once, check it against the rules below, and copy from it every time a form asks.

The owners table in the NEMT credentialing checklist is the short version for broker files. This worksheet holds everything the full Medicaid disclosure asks, and the guide to becoming a Medicaid transportation provider covers the rest of the application.

How to use this template

1. Gather the papers that show who owns what. You need your articles of organization or incorporation, your operating agreement or bylaws, your membership or stock ledger, and every loan agreement secured by company assets.
2. Fill in Parts 1 to 3 from those papers. Use each person’s full legal name. Louisiana’s instructions, for example, ask for the full legal name, never initials or a nickname.
3. Do the math in Parts 4 and 5. Multiply through each layer of ownership and each secured loan, and report every result of 5 percent or more.
4. Name your managing employees in Part 7. Anyone who runs the day while you drive, such as an office manager, may count.
5. Answer every question in Part 11 for every person. Attach a written explanation and the court or agency papers for each yes.
6. Protect the filled copy. It holds birth dates and Social Security numbers. Keep it locked, or write only the last four digits here and keep the full numbers in a locked file.
7. Search each new name before you add it. Check the OIG exclusion list and SAM exclusions, and record the dates in your exclusion screening log.
8. Log every filing and every change. Parts 13 and 14 show what each agency and broker has on file, and when the next update is due.

The template

Part 1: Your company

Field	Entry
Legal name, exactly as the IRS has it
Doing business as (DBA) names
Other names or tax ID numbers the company has used
Employer identification number (EIN)
NPI
Medicaid provider number in each state
Entity type: sole proprietorship / partnership / corporation / LLC / nonprofit
State and date of formation
Publicly traded: yes / no
Primary business address
Every other business location, including garages and offices
Every P.O. box
Contact for official notices: name, email, phone

Part 2: Owners who are people

One column for each person with a direct, indirect, or combined ownership interest of 5 percent or more. Copy the page if you need more columns.

Field	Owner 1	Owner 2	Owner 3
Full legal name
Other names used: maiden, married, alias
Title in the company
Direct ownership percent
Indirect ownership percent, from Part 4
Combined percent
Date of birth
Social Security number, last four
Home address
Mailing address, if different
U.S. citizen: yes / no
Lives in another state: yes / no, and any Medicaid or Medicare numbers there
Exclusion searches done (date)

Part 3: Owners that are companies

Field	Company owner 1	Company owner 2
Legal name and DBA
EIN
Percent of your company it owns
Primary business address
Every other business location
Every P.O. box
Other names it has used
Its own owners, carried to Part 4

Part 4: Indirect owners

Multiply each owner’s share of the company in Part 3 by that company’s share of yours. Report 5 percent or more.

Owner company (Part 3)	Its owner	Share of the owner company	Owner company’s share of yours	Indirect share	Report
Example: Main Street Holdings LLC	A. Owner	10%	80%	8%	Yes

Part 5: Lenders and note holders

One row for each mortgage, note, or other loan secured by company property or assets. Multiply the holder’s share of the loan by the share of your assets that secure it. Report 5 percent or more.

Lender or note holder	Share of the loan it holds	Share of your assets securing it	Interest	Report
Example: a note holder	10%	60%	6%	Yes

Part 6: Officers, directors, and partners

Corporations, including nonprofit corporations, list every officer and director, paid or not. Partnerships list every general and limited partner at any percentage. Nonprofits with trustees list the trustees.

Name	Role	Date of birth	SSN, last four	Home address

Part 7: Managing employees and agents

A managing employee runs or controls the day-to-day operation. An agent has authority to obligate or act for the company, such as signing contracts or claims.

Name	Title and what they run	Managing employee or agent	Date of birth	SSN, last four	Home address

Part 8: Family ties

One row for each pair of people in Parts 2 and 6 who are spouses, parents, children, or siblings of each other. Add owners of any subcontractor you own 5 percent or more of who are related to someone in Parts 2 or 6. Some states also ask about agents and managing employees.

Person	Related to	Relationship
		Spouse / parent / child / sibling
		Spouse / parent / child / sibling
		Spouse / parent / child / sibling

Part 9: Other providers and subcontractors your owners hold

Other Medicaid or Medicare providers in which any owner has an ownership or control interest:

Owner	Other provider’s legal name and DBA	EIN	NPI	Program and state

Subcontractors in which your company holds 5 percent or more:

Subcontractor	Your share	Its owners	Tax ID of each company owner	Related to your owners

Part 10: Business transactions

Keep this current. The state or HHS can ask for it, and you then have 35 days to answer.

Subcontractors you did more than $25,000 in business with in the last 12 months:

Subcontractor and what it does for you	Total in the last 12 months	Who owns it

Transactions in the last 5 years over the lesser of $25,000 or 5 percent of your operating costs in one fiscal year, with any subcontractor or with a supplier your company or your owners wholly own:

Supplier or subcontractor	Fiscal year	Amount	Who owns it

Part 11: Criminal and program history

Answer for the company and for each owner, agent, and managing employee. The first question is the federal minimum. State forms often ask the rest.

Question	Yes or no	Who, with details attached
Ever convicted of a crime related to Medicare, Medicaid, or the Title XX social services program
Ever excluded, suspended, denied enrollment, or terminated by a health care program, or withdrawn to avoid that
Owes money now to Medicare, Medicaid, or another government health program
Ever convicted of any felony
Ever had a health care license or certification disciplined, suspended, or surrendered
Ever investigated by a law enforcement, regulatory, or state agency, or in an open health care court case now

Part 12: Affiliations, where your state asks

Ties in the last 5 years to any Medicare, Medicaid, or CHIP provider with an unpaid program debt, a payment suspension, an exclusion, or a denied, revoked, or terminated enrollment.

Affiliated provider	EIN and NPI	Who has the tie, and what kind	Years	What happened

Part 13: Who signs, and where each disclosure went

Person authorized to sign disclosures for the company, and their title: ________

Agency, plan, or broker	Form name and version	Signed by	Date sent	Confirmation
State Medicaid agency

Part 14: Change log

Date of change	What changed	Federal deadline (35 days)	State deadline	Sent to the state	Sent to each broker and plan

Who counts as an owner, officer, or managing employee

The rules apply to your company as a disclosing entity, which federal rules define as any Medicaid provider other than an individual practitioner or a group of practitioners (42 CFR 455.101). A NEMT company is one. Under the same section, a person with an ownership or control interest is a person or company that:

• Owns 5 percent or more of the company, directly, indirectly, or in combination.
• Holds 5 percent or more of a mortgage, deed of trust, note, or other obligation secured by the company, if that interest equals at least 5 percent of the company’s property or assets.
• Is an officer or director of a company organized as a corporation.
• Is a partner in a company organized as a partnership.

A managing employee is a general manager, business manager, administrator, director, or anyone else who exercises operational or managerial control over the day-to-day operation, or conducts it, whether or not the person is a W-2 employee. An agent is anyone delegated the authority to obligate or act on behalf of the company.

CMS’s Medicaid Provider Enrollment Compendium (last updated November 17, 2025, section 1.4.1) settles the common questions:

• No exceptions for public companies or managers. There is no exception for publicly traded companies, and no exception to the managing employee disclosure.
• Every officer and director. All officers and directors are disclosed, whatever their number and even if unpaid. Nonprofit trustees count. Officers and directors of a company that owns yours are not disclosed as such, unless they also hold that role in your company.
• Every partner. General and limited partners are disclosed at any percentage.
• Titles do not decide it. A finance director who is not on the board is not disclosed as a director, but may still be a managing employee.
• One-owner LLCs. If your company is a single-member LLC that the IRS disregards for tax purposes, its owner still holds 100 percent and goes in Part 2. CMS suggests states confirm such a company’s legal name and tax ID from a government form such as a W-9.

How to count indirect owners and lenders

Indirect ownership is figured by multiplying the percentages through each layer (42 CFR 455.102). If a person owns 10 percent of a company that owns 80 percent of yours, the person holds 8 percent and must be reported. If a person owns 80 percent of a company that owns 5 percent of yours, the person holds 4 percent and need not be. CMS’s compendium adds that direct and indirect owners go on the same enrollment record, never a separate one, and that the combined percentages may add up to more than 100.

Loans work the same way. Multiply the holder’s share of the obligation by the share of your assets that secure it. Holding 10 percent of a note secured by 60 percent of your assets equals 6 percent and is reported. Holding 40 percent of a note secured by 10 percent of your assets equals 4 percent and is not. The compendium says these disclosures frequently include banks, other financial institutions, and investment firms. Work out each van loan and any loan secured by all of your business assets in Part 5.

What else the disclosure asks

Beyond names and percentages, 42 CFR 455.104(b) requires:

• Identifiers. The name and address of each owner, with every business location and P.O. box for a company owner. The date of birth and Social Security number of each individual. The tax ID of each company with an ownership or control interest in you, or in a subcontractor you own 5 percent or more of.
• Family ties. Whether any person with an ownership or control interest, which includes officers, directors, and partners, is the spouse, parent, child, or sibling of another such person, and whether an owner of a subcontractor you hold 5 percent or more of is related that way to one of them.
• Other providers. The name of any other disclosing entity in which one of your owners has an ownership or control interest.
• Managing employees. The name, address, date of birth, and Social Security number of each one.

Three related sections fill in the rest of Parts 10 to 12:

• Business transactions. Within 35 days of a request from the state or HHS, you report who owns any subcontractor whose business transactions with you totaled more than $25,000 in the 12 months before the request, and any significant business transaction in the past 5 years with a subcontractor or a wholly owned supplier (42 CFR 455.105). A significant transaction is one, or a series in a fiscal year, above the lesser of $25,000 and 5 percent of your operating expenses. A supplier is a business you buy goods or services from to carry out your Medicaid work. A wholly owned supplier is one owned entirely by your company or by people with an ownership or control interest in it, such as a repair shop you own that services your vans.
• Criminal convictions. Before the state signs or renews your agreement, or whenever it asks in writing, you disclose any owner, agent, or managing employee convicted of a crime related to Medicare, Medicaid, or the Title XX services program since those programs began. The state reports each disclosure to the HHS Inspector General within 20 working days (42 CFR 455.106).
• Affiliations. Each state chooses, with CMS, whether to collect affiliations from every new or revalidating provider not enrolled in Medicare, or only when it believes a provider may have one. An affiliation counts when you or an owner or managing employee has, or had in the last 5 years, a tie to a provider with an unpaid program debt, a payment suspension, an exclusion, or a denied, revoked, or terminated enrollment (42 CFR 455.107).

When to file and update it

Federal rules make the disclosure due when you apply, when you sign the provider agreement, when the state asks during revalidation, and within 35 days after any change in ownership (42 CFR 455.104(c)). All of it goes to the state Medicaid agency. States must revalidate every provider at least every 5 years (42 CFR 455.414), so expect to answer every question again; Medicaid revalidation covers that cycle. Some states set clocks shorter than 35 days for some changes, and how to report changes to Medicaid lists them.

Brokers keep their own rules. MTM Health’s standard agreement, in the January 1, 2023 version Pennsylvania posts, requires you to report any change in ownership, corporate officers, directors, or controlling interest immediately, and to provide a disclosure of ownership, controlling interest, and management on request (section 11.B). A change of ownership, a new federal tax ID, or a new legal name requires a new agreement (section 2.C).

CMS’s compendium also says states may not hand off collection of these disclosures in a way that has one provider give the same personal information to more than one entity, because of the risk of data breaches. If a health plan asks for owners’ full Social Security numbers again, ask whether the state already has them.

Worked example: your spouse becomes a 50 percent owner

Say you own 100 percent of your NEMT company and transfer half to your spouse. Here is what changes:

1. Search your spouse first. States must check every owner, agent, and managing employee against federal exclusion databases at enrollment, and the OIG list and the excluded parties list in SAM.gov at least monthly (42 CFR 455.436). A 5 percent owner convicted of a Medicare, Medicaid, or CHIP crime in the last 10 years generally means denial or termination (42 CFR 455.416(b)).
2. Update the worksheet. Your spouse goes in Part 2 at 50 percent, your own share drops to 50 percent, and Part 8 gets a row: owner related to owner as spouse. If your spouse also runs the office, add them to Part 7.
3. File with the state within 35 days of the transfer, or sooner if your state’s rule is shorter. Log the date in Part 14.
4. Be ready for fingerprints. If your state rates your company high risk, each 5 percent owner must submit fingerprints, and anyone asked has 30 days to send them (42 CFR 455.434).
5. Tell every broker and plan the same day. Under MTM Health’s agreement, report the change immediately and ask whether it counts as a change of ownership that needs a new agreement.

If you are selling the company instead, see how to sell a NEMT business and change of ownership.

What a state form adds: Louisiana and Arkansas

State forms build on the federal list. Louisiana’s entity ownership disclosure (instructions revised May 2023) shows how far one can go:

• Every field, every question. The instructions say an incomplete form will be rejected, and the same form serves new enrollment, updates, revalidation, re-enrollment, and change of ownership.
• One section per person. Each owner gets a full Section V(b), and each managing employee or agent a Section VI(b). A list of names is not accepted.
• More about each person. It asks for maiden and other names, citizenship, and, for owners living outside Louisiana, their Medicaid and Medicare numbers there. Its relationship question covers owners, agents, managing employees, and subcontractor owners, wider than the federal rule.
• More history. Beyond program crimes, it asks about felony convictions of any type, license discipline, program exclusions and terminations, money owed to state or federal programs, investigations, and open health care court cases.
• Who signs. Only an authorized representative listed on the form as an owner or managing employee may sign, with an original signature in blue ink. Stamps and initials are not accepted.

Arkansas shows that the answers may not stay private. Its Department of Human Services links, from its NET program page, a document listing the owners and board members of three Non-Emergency Transportation brokers and of the transportation companies that subcontract with them (file created June 28, 2023, and still linked as of October 2026). Region G moved to a new broker on January 2, 2026, and that broker is not in the file. Arkansas runs its NET brokers as prepaid ambulatory health plans under a federal waiver approved effective April 1, 2023 through March 31, 2028. If you drive for an Arkansas NET broker, your owners’ names may be posted there too.

What happens when the disclosure is wrong or late

The penalties fall on your payments and your enrollment:

• Payments. Federal matching funds are not available for payments to a provider that fails to disclose ownership or control information (42 CFR 455.104(f)). For a late answer to a business transaction request, they are denied for services from the day after the answer was due until the day before you supply it (42 CFR 455.105(c)).
• Owners who do not cooperate. The state must end your enrollment if any 5 percent owner does not give timely and accurate information and cooperate with screening (42 CFR 455.416(a)).
• Inaccurate answers. The state must deny or end enrollment when the company or any owner, agent, or managing employee fails to submit timely or accurate information, unless it documents in writing that this would not serve the program (455.416(d)). It may also refuse or end your agreement over an incomplete criminal disclosure (455.106(c)).
• Fingerprints. The state must deny or end enrollment if the company or a 5 percent owner does not submit fingerprints within 30 days of a request, with the same written exception (455.416(e)).

If a disclosure problem has already led to a denial, Medicaid application denied covers what to do next.