318-22 Exhibit A-Coronis Health for Emergency Transport Third Party Billing - 2022.pdf

FORM BE BUSINESS ENTITY ANNUAL STATEMENT NEW JERSEY ELECTION LAW ENFORCEMENT COMMISSION (609) 292-8700 or Toll Free Within NJ 1-888-313-ELEC (3532) THIS FORM MUST BE ELECTRONICALLY FILED AT: www.elec.nj.gov FOR STATE USE ONLY This statement is required to be filed by a business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities. Part 1: General Information Date of Statement December 6, 2021 __ Activity for Calendar Year 2021 LF] CheckifAmendment Part 2: Business Entity Information Business Name Coronis Health RCM, LLC Business Type Other Business Organization Address 1 5963 Exchange Drive Address 2 City Sykesville __ State Maryland _ Zip 21784 *(Area Code) Telephone Number ACKNOWLEDGEMENT | have been authorized by the above named business entity to complete the annual statement, and certify that the statements and/or information contained herein are true. | am aware that if any of the statements or information are willfully false, | may be subject to punishment. First Name Vlad Last Name Busko Title/Position Staff Accountant __ Date December 6, 2021 *(Area Code) Telephone Number 410-753-3358 Check this box to certify the above acknowledgement. A business entity which has received $50,000 or more in the aggregate during a calendar year through agreements or contracts with a public entity or public entities, but has made no contributions to candidates or committees, shall file the business entity annual disclosure statement with the Commission to report that no contributions were made during the calendar year. [x] Check this box if the business entity has not made any reportable contributions during the calendar year. *Leave this field blank if your telephone number is unlisted, Pursuant to NJ1S.A. 47:1-1.1, an unlisted telephone number is not a public record and must not be provided on this form. New Jersey Election Law Enforcement Commission Page 1 of 1 Form BE Revised Dec, 2020