DISCLOSURE OF OWNERSHIP AND
CONTROL INTEREST STATEMENT

In accordance with 42 CFR, Part 455, Subpart B, and as required by CMS, individual physicians and
other healthcare professionals must disclose criminal convictions, while facilities and businesses
must additionally disclose ownership and control interest, prior to payment for any services
rendered to Medicare or Medicaid enrollees. It is your responsibility as a contracted provider to
ensure your forms are updated to reflect any changes to information previously provided. Updated
disclosure forms are generally required every three (3) years.

MARCH® Vision Care only requires Disclosure Forms from these states: LA, MA, MN, NJ and NY. All other states are required to submit forms to the state.

Please complete the appropriate disclosure forms for BOTH the individual and group, for your
respective state. To download the appropriate form, please select your state below:

In order to comply with Federal Regulations, effective December 1, 2014, MARCH® Vision
Care will suspend payment to providers who have failed to comply and have not submitted a
valid and completed disclosure form to MARCH® Vision Care.

Completed and signed Disclosures can be emailed to providers@marchvisioncare.com.