KMAP GENERAL BULLETIN 14133 DOO Form Update The Disclosure of Ownership and Control Interest Statement (DOO) form has been updated on the Kansas Medical Assistance Program (KMAP) website in an effort to reduce errors upon completion. The KMAP provider enrollment applications now include the updated portion. The updated form is also available on the Forms page under the Provider Information heading. To ensure identification of group physicians who are related to any owner and/or party with a controlling interest, the following question was added for group providers on page 3 of the DOO form: Do any group physicians have a relationship to an owner or controlling interest holder listed in question #1? NOTE: Designate relationship to each person listed in question #1 by using 1A, 1B, 1C, etc. KMAP Kansas Medical Assistance Program • Bulletins • Manuals • Forms Customer Service • 1-800-933-6593 (in-state) • 785-274-5990 8:00 a.m. - 5:00 p.m. Monday - Friday HP Enterprise Services is the fiscal agent of KMAP. Page 1 of 1
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