Form HCA09-048 Medicaid Provider Disclosure Statement - Washington

Form HCA09-048 Medicaid Provider Disclosure Statement - Washington

What Is Form HCA09-048?

This is a legal form that was released by the Washington State Health Care Authority - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form HCA09-048?
A: Form HCA09-048 is the Medicaid Provider Disclosure Statement for Washington State.

Q: Who needs to fill out Form HCA09-048?
A: Medicaid providers in Washington State need to fill out Form HCA09-048.

Q: What is the purpose of Form HCA09-048?
A: Form HCA09-048 is used to disclose information about the provider's ownership, control, and affiliations.

Q: How do I fill out Form HCA09-048?
A: You need to provide information about your ownership, control, and affiliations, as well as sign and date the form.

Q: What happens after I fill out Form HCA09-048?
A: The Washington State Health Care Authority will review your disclosure and determine if any further action is needed.

Q: Is there a deadline for submitting Form HCA09-048?
A: Yes, you must submit Form HCA09-048 within 30 days of becoming a Medicaid provider in Washington State.

Q: Are there any fees associated with Form HCA09-048?
A: No, there are no fees associated with submitting Form HCA09-048.

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Form Details:

  • Released on November 1, 2012;
  • The latest edition provided by the Washington State Health Care Authority;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HCA09-048 by clicking the link below or browse more documents and templates provided by the Washington State Health Care Authority.

Download Form HCA09-048 Medicaid Provider Disclosure Statement - Washington

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