4601.1 An application to participate in the Medicaid/MCOTT Program shall be filed on forms provided by MAA.

4601.2 The MCOTT Application shall contain, but not be limited to, the following information:

1. (a) Name and address of the Provider organization and location of all of the Provider's places of business in the District or elsewhere in the United States;
2. (b) Names and addresses of the owners of the Provider organization;
3. (c) If the Provider organization is a corporation, the application shall include the names and addresses of all persons having a five percent (5%) or greater ownership interest and all officers and directors;
4. (d) The name of the physician who will be responsible for directing the services of the Provider's MCOTT Program; and
5. (e) The name of the Program Director.

SOURCE: Final Rulemaking published at 46 DCR 6122(July 23, 1999).