Get Form Mcsa 5871 2020-2024

Disclosing entity means: (1) A provider of services, an independent clinical laboratory, a renal disease facility, a rural health clinic, a Federally qualified health center, or a health maintenance organization (as defined in section 1301(a) of the Public Health Service Act);

A distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses; A field of vision of at least 70 degrees in the horizontal Meridian in each eye; The ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.

The Disclosure of Ownership is a Center for Medicare and Medicaid Services (CMS) and Client Required document to obtain during the contracting/credentialing process. If this documentation is not received, the credentialing process will be delayed.

About the Vision Evaluation Report, Form MCSA–5871: The Medical Examiner must receive a completed Vision Evaluation Report, Form MCSA–5871, that is signed and dated by an ophthalmologist or optometrist before each required physical qualification examination.

Form 5871-S is completed and submitted as a condition of approval or renewal of a Texas Medicaid enrollment application or a contract agreement between the disclosing entity (applicant/provider) and HHSC for any services program. A full and accurate disclosure of ownership and control interest is required.