(a) Any person, corporation, partnership, or facility seeking a license or renewal to provide long-term care in this state shall furnish a current annual disclosure statement to all residents upon request or to all prospective residents upon request.

(b) The statement shall be filed along with the annual application for licensure by March 1 of each year.

(c) The statement shall be on forms and in a format as prescribed by the Department of Human Services and shall include the following information:

(1) The name and business address of the facility and a statement as to whether the facility is a partnership, corporation, or other type of legal entity;

(2) The names and business addresses of the officers, directors, trustees, managing or general partners, or any persons having a five percent (5%) or greater equity or beneficial interest in or of the facility and a description of each person's interest in or occupation with the facility;

(3) A statement as to whether the facility, or any of its officers, directors, trustees, partners, or administrators, prior to the date of application:

(A) Has ever been convicted of Medicare or Medicaid fraud or felony;

(B) Has ever been convicted of fraud, embezzlement, fraudulent conversion, or misappropriation of property; or

(C) Has had final administrative judgment on any Class A or Class B violations within the last two (2) years;

(4) The location and description of the physical property or property of the facility;

(5) The disclosure statement shall clearly state which services are included in basic care contracts for long-term care and which services are available at or by the facility at extra charge; and

(6) A copy of the contract used by the facility.