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101, must complete this form in order to enroll as a provider in the Medicaid program. If ownership does not total 100 percent, the provider must submit a letter explaining the discrepancy.Are there any exceptions to the disclosure obligation? This subpart implements sections 1124, 1124A, 1126, and 1861(v)(1)(i) of the Social Security Act. The entity must have an authorized person (i.e. Identify each item number to be continued. Please answer all questions and complete the information requested. (Molina) where Molina members will be seen. Likewise, State Medicaid agencies should collect ownership and control disclosures under section 455. If there are any changes to the information disclosed on this form, an updated form should be completed and submitted to Home State Health Plan.