South Country Health Alliance, along with other Minnesota health plans, is required by the Centers for Medicare & Medicaid Services (CMS) and the Minnesota Dept. of Human Services (DHS) to collect this information from you.
You are required to complete this form in its entirety:
- As a condition of South Country Health Alliance participation;
- Upon credentialing and re-credentialing with South Country Health Alliance;
- When any information on your Ownership and Control Interests Disclosure Statement changes; and
- When contracting with South Country Health Alliance to provide services related to its medical programs.
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