Governmental Status of Health Care Provider

1.) Is the health care provider directly operated by a unit of government within the State?
Yes No

2.) Does the unit of government that operates the health care provider have generally applicable taxing authority?
Yes No

If no, move to number 7.

If yes:

Describe type of taxing authority

Describe source(s) of tax revenue

Move to number 3.

3.) Does the unit of government that operates the health care provider appropriate generally applicable tax revenue to the health care provider?
Yes No

If no, move to number 4.

If yes:

Specify total dollar amount of current year appropriation to the health care provider from the unit of government that operates the health care provider. $

Describe purpose of appropriation to the health care provider from the unit of government that operates the health care provider

Move to number 4.

4.) Does the health care provider appear on the government's consolidated annual financial report as a component unit?
Yes No

If no, move to number 6.

If yes, please provide copy of the most recent consolidated annual financial report.

How to Submit Supporting Documents - Details

How to Submit Supporting Documents - Details

You may submit documents by email ( CertifiedSeedSurvey.DHHS@maine.gov ) or by fax 207-287-8450.

On the fax cover sheet, please list the subject as Certified Seed Provider Survey and include your MaineCare provider name and ID#.

You may also mail the documents to:
  MaineCare Services, Provider Enrollment Unit
  442 Civic Center Drive
  Augusta, ME 04333.

These instructions will be included in your submission confirmation e-mail

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Move to number 5.

5.) Based upon information from the government's consolidated annual financial report. the government's budget/appropriation, applicable law, or other sources, does the government have an obligation to fund the health care provider's:

Expenses? Yes No

Liabilities? Yes No

Deficits? Yes No

For each yes, please forward supporting documentation.

How to Submit Supporting Documents - Details

How to Submit Supporting Documents - Details

You may submit documents by email (CertifiedSeedSurvey.DHHS@maine.gov) or by fax 207-287-8450.

On the fax cover sheet, please list the subject as Certified Seed Provider Survey and include your MaineCare provider name and ID#.

You may also mail the documents to:
  MaineCare Services, Provider Enrollment Unit
  442 Civic Center Drive
  Augusta, ME 04333.

These instructions will be included in your submission confirmation e-mail

Close this window

Move to number 6.

6.) Is a contract with the unit of government necessary in order for the health care provider to receive tax revenues?
Yes No

If yes, please explain.

THE RESPONSE IS COMPLETE AT THIS POINT.

7.) Does the unit of government with no taxing authority, which is operating the health care provider, receive an appropriation from another unit of government within the the State that has taxing authority?
Yes No

If no, THE RESPONSE IS COMPLETE AT THIS POINT.

If yes, please provide the following information concerning the unit of government with taxing authority:

a. Describe type of taxing authority.
b. Describe source(s) of tax revenue
c. Provide the source of the current year appropriation.
d. Provide the total amount of the current appropriation $
e. Provide purpose of current year appropriation.

Move to number 8.

8.)

a. Does the health care provider appear as a component unit of government on the consolidated annual financial report of the unit of government with no taxing authority?

If yes, please provide copy of most recent consolidated annual financial report.

Move to 8b.

b. Does

a) the unit of government with no taxing authority that is operating the health care provider and/or

b) the health care provider

appear as a component unit of government on the consolidated annual financial report of the unit of government with taxing authority?
Yes No

If no, THE RESPONSE IS COMPLETE AT THIS POINT.

If yes, please provide copy of most recent consolidated annual financial report.

Move to number 9.

9.) a. Based on information from the consolidated annual financial report of the unit of government without taxing authority, that government's budget/appropriation, applicable law, or other sources, does the government without taxing authority have an obligation to fund the following for the health care provider?

Expenses? Yes No

Liabilities? Yes No

Deficits? Yes No

For each yes, please forward supporting documentation.

How to Submit Supporting Documents - Details

How to Submit Supporting Documents - Details

You may submit documents by email (CertifiedSeedSurvey.DHHS@maine.gov) or by fax 207-287-8450.

On the fax cover sheet, please list the subject as Certified Seed Provider Survey and include your MaineCare provider name and ID#.

You may also mail the documents to:
  MaineCare Services, Provider Enrollment Unit
  442 Civic Center Drive
  Augusta, ME 04333.

These instructions will be included in your submission confirmation e-mail

Close this window

Move to number 9b.

b. Based on information from the consolidated annual financial report of the unit of government with taxing authority, that government's budget/appropriation, applicable law, or other sources, does the government with taxing authority have an obligation to fund the following for the unit of government with no taxing authority that is operating the health care provider?

Expenses? Yes No

Liabilities? Yes No

Deficits? Yes No

For each yes, please forward supporting documentation.

How to Submit Supporting Documents - Details

How to Submit Supporting Documents - Details

You may submit documents by email (CertifiedSeedSurvey.DHHS@maine.gov) or by fax 207-287-8450.

On the fax cover sheet, please list the subject as Certified Seed Provider Survey and include your MaineCare provider name and ID#.

You may also mail the documents to:
  MaineCare Services, Provider Enrollment Unit
  442 Civic Center Drive
  Augusta, ME 04333.

These instructions will be included in your submission confirmation e-mail

Close this window

Move to number 9c.

c. Based on information from the consolidated annual financial report of the unit of government with taxing authority, that government's budget/appropriation, applicable law, or other sources, does the government with taxing authority have an obligation to fund the following for the health care provider?

Expenses? Yes No

Liabilities? Yes No

Deficits? Yes No

For each yes, please forward supporting documentation.

Move to number 10.

10.) a. Is a contract with the unit of government with taxing authority necessary in order for the unit of government with no taxing authority which is operating the health care provider to receive tax revenues?
Yes No

If yes, please explain.

Move to number 10b.

b. Is a contract with the unit of government with taxing authority necessary in order for the health care provider to receive tax revenues?
Yes No

If yes, please explain.

Move to number 10c.

c. Is a contract with the unit of government without taxing authority necessary in order for the health care provider to receive tax revenues?
Yes No

If yes, please explain.

THE RESPONSE IS COMPLETE AT THIS POINT.

11.) Does the health care provider appear as a component unit on the consolidated annual financial report of a unit of government with taxing authority?
Yes No

If no, Move to number 13.

If yes, please provide a copy of the most recent consolidated annual financial report of that unit of government.

How to Submit Supporting Documents - Details

How to Submit Supporting Documents - Details

You may submit documents by email (CertifiedSeedSurvey.DHHS@maine.gov) or by fax 207-287-8450.

On the fax cover sheet, please list the subject as Certified Seed Provider Survey and include your MaineCare provider name and ID#.

You may also mail the documents to:
  MaineCare Services, Provider Enrollment Unit
  442 Civic Center Drive
  Augusta, ME 04333.

These instructions will be included in your submission confirmation e-mail

Close this window

Move to number 12.

12.) Based on information from the consolidated annual financial report of the unit of government with taxing authority, that government's budget/appropriation, applicable law, or other sources, does the government have an obligation to fund the health care provider's:

Expenses? Yes No

Liabilities? Yes No

Deficits? Yes No

For each yes, please forward supporting documentation.

How to Submit Supporting Documents - Details

How to Submit Supporting Documents - Details

You may submit documents by email (CertifiedSeedSurvey.DHHS@maine.gov) or by fax 207-287-8450.

On the fax cover sheet, please list the subject as Certified Seed Provider Survey and include your MaineCare provider name and ID#.

You may also mail the documents to:
  MaineCare Services, Provider Enrollment Unit
  442 Civic Center Drive
  Augusta, ME 04333.

These instructions will be included in your submission confirmation e-mail

Close this window

Move to number 13.

13.) Is a contract with the unit of government with taxing authority necessary in order for the health care provider to receive tax revenues?
Yes No

If yes, please explain.