Participating Provider Owner/Manager Disclosure Certification

In accordance with the New York State Department of Health Standard Clauses for Managed Care Provider/IPA Contracts section B(9)(l), providers are required to have an officer, director or partner of the Provider execute the following certification within 5 days of executing a new agreement with a Medicaid Managed Care Organization (MCO). The MCO must retain this document with the applicable contract for validation during operational surveys.

Questions regarding this certification can be directed to BMCCSProgInt@health.ny.gov