Laserfiche WebLink
<br /> ~- <br /> /I/V <br /> - ~ of HMJth md HutrWJ s.mca .. . - . Fonn ~ <br /> ~ "~~TIQ Io.dmlnl$tnrtion . OM B No. 0938-00SS <br /> DISCLOSURE OF OWNERSHIP AND CONTROL INTEREST STATEMENT <br /> . . <br /> I. Infom1ation <br /> (8). Name of Entity OIBI A Pn:Mder No. Vendor No. Telephone No . <br /> '0 <br /> CITY OF SAN MARCOS ~,¡'IC PROGRAM (512) 353-530:; <br /> 3trMt Addr88a CIty, -County, State Zip Code <br /> ., - - - .-- - ----- --r . '0- <br /> 630 E. HOPKINS MARCOS. HAYS. TEXAS <br /> SAN 78666 <br /> bj (To M ~àId by HCFA: R~ Ot'ffoeJ Chain Affiliate No. 00000 LB1 <br /> I. Asw:" .-- the following questionS by checlång "Yes" or "No". If any of the questionS are answered "Yes", fist names and addresses of individuals or <br /> :cxpco ... under Remarlc:s on page 2. identify Nd1 item number to be continued. - " <br /> - <br /> A Are therø any individuals Of organizations having a dirøct or indirect owneratúp or control interest of 5 percent or more in the institution, <br /> ~, or agency that have been c:onviçted of a criminal offense related to the involvement of such persons, or organizations in any of <br /> the programs estabIïsned by Titles XVIII, XIX, or XX? <br /> D Yes ŒJ No L82 <br /> 8. Are there any directors, officers, agents, or managing employees of the institution, agency or organization who have ever been convicted of a <br /> criminal offense related to their Involvement in such programs established by Titles XVIII, XIX, or XX? <br /> DYes W No LB3 <br /> C. Are there any individuals currently employed by the institution. agency, or organization in a managerial. accounting, auditing, or similar <br /> capacity who were employed by the Institution's, organization's, or agency's fiscal intermediary or carrier within the previous 12 months? <br /> (Title XVIII providers only) <br /> . <br /> DYes GJ No LB4 <br /> I. (a) Ust names, addresses for individuals, or the EIN for organizations having direct or indirect ownership or a controlling interest in the entity. <br /> (See instructions for definition of ownership and, controlling interest.) Ust any additional names and addresses under "Remarks" on Page 2. If <br /> more than one individual is reported and any of these persons are related to each other, this must be reported under Remarks. <br /> .. <br /> Name I Address I EfN <br /> LB5 <br /> - I I <br /> - <br /> (b) Type of Entity: 0 Sole Proprietorship 0 Partnership 0 Corporation LB6 <br /> 0 Unincorporated Associations [X] Other (Specify) M un i c i pal i t Y <br /> (c) If the disclosing entity is a corporation, list names, addresses of the Directors, and EINs for corporations under Remarks. <br /> heck appropriate box for each of the following questions <br /> (d) Are any owners of the disclosing entity also owners of other MedicarelMedicaid facilities? (Example, sole proprietor, partnership or members <br /> of Board of Directors.) If yes, list names, addresses of individuals and provider numbers. Dyes 5J No <br /> LB7 <br /> Name I Address Providef Number <br /> - <br />