Cms-855s

Medicare Enrollment Application

CMS-855S

Medicare Enrollment Application

OMB: 0938-0685

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0685 can be found here:

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MEDICARE ENROLLMENT APPLICATION
Durable Medical Equipment, Prosthetics, Orthotics,
and Supplies (DMEPOS) Suppliers

CMS-855S

SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION.
SEE PAGE 2 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION.

SEE PAGE 30 FOR A LIST OF SUPPORTING DOCUMENTS THAT MUST BE SUBMITTED
WITH THIS APPLICATION.
SEE PAGE 31 FOR A LIST OF THE DMEPOS SUPPLIER STANDARDS. EVERY
APPLICANT MUST MEET AND MAINTAIN THESE ENROLLMENT STANDARDS.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0685

WHO SHOULD SUBMIT THIS APPLICATION
The following types of DMEPOS suppliers must complete this application to initiate the enrollment process:
Pharmacy
Medical Supply Company
Ambulatory Surgical Center
Physical Therapist
Occupational Therapist
Department Store
Physician
Optician
Grocery Store
Prosthetics Personnel
Optometrist
Home Health Agency
Prosthetic/Orthotic Personnel
Orthotics Personnel
Hospital
Rehabilitation Agency
Oxygen Supplier
Indian Health Service
Skilled Nursing Facility
Intermediate Care Nursing Facility Pedorthic Personnel

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If your DMEPOS supplier type is not listed, contact the National Supplier Clearinghouse (NSC) before
you submit your application.

Complete this application if you plan to bill Medicare for DMEPOS and you are:
• Enrolling in Medicare for the first time as a DMEPOS supplier.
• Currently enrolled in Medicare as a DMEPOS supplier and need to report changes to your business,
other than enrolling a new business location (e.g., you are adding, deleting, or changing existing
information under this Medicare supplier billing number). Changes must be reported within 30 days
of the effective date of the change.
• Currently enrolled in Medicare as a DMEPOS supplier but need to enroll a new business location. This
is to add a new location to an organization with a tax identification number already listed with the
NSC. (This differs from changing information on an already existing location.)
• Currently enrolled in Medicare as a DMEPOS supplier and have been asked to verify or update your
information. This includes situations where you have been asked to attest that your organization is still
eligible to receive Medicare payments.
• Reactivating your Medicare DMEPOS supplier billing number (e.g., your Medicare supplier billing
number was deactivated because of non-billing, and you wish to receive payment from Medicare for
future claims).
• Voluntarily terminating your Medicare DMEPOS supplier billing number.
BILLING NUMBER INFORMATION

The Medicare Identification Number, often referred to as a Medicare supplier number, is a generic term for
any number other than the National Provider Identifier (NPI) that is used by a supplier to bill the Medicare
program.

The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and
is assigned by the National Plan and Provider Enumeration System (NPPES). As a new Medicare DMEPOS
supplier, you must obtain an NPI and submit it with this application prior to enrolling in Medicare or before
submitting a change to your existing Medicare enrollment information. Applying for the NPI is a process
separate from Medicare enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov.
For more information about NPI enumeration, visit www.cms.hhs.gov/NationalProvIdentStand.

CMS-855S (10/07)

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION
• Type or print all information so that it is legible. Do not use pencil.
• Attach all supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your own records and for updating
your information.

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AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should:
• Complete all required sections.
• Ensure that the correspondence address shown in Section 2 is the supplier’s address.
• Enter your NPI in the applicable section.
• Enter all applicable dates.
• Send the completed application with all supporting documents to the NSC.
OBTAINING MEDICARE APPROVAL

The usual process for becoming a Medicare DMEPOS supplier is as follows:
1. The applicant completes and submits an enrollment application (CMS-855S) and all supporting
documentation to the NSC.
2. The NSC reviews the application and conducts a site visit to verify compliance with the 21 DMEPOS
Supplier Standards (see 42 CFR 424.57).
3. After completing its review, the NSC notifies the applicant in writing about its enrollment decision.
ADDITIONAL INFORMATION

For additional information regarding the Medicare enrollment process, visit
www.cms.hhs.gov/MedicareProviderSupEnroll.

The NSC may request, at any time during the enrollment process, documentation to support or
validate information reported on the application. You are responsible for providing this documentation
in a timely manner.
The information you provide on this form will not be shared. It is considered to be protected under 5
U.S.C. Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page for the
Privacy Act Statement.
MAIL YOUR APPLICATION

The NSC is responsible for processing your enrollment application.

National Supplier Clearinghouse
Post Office Box 100142
Columbia, SC 29202-3142
Phone: 1-866-238-9652

Web: www.palmettogba.com/NSC

CMS-855S (10/07)

SECTION 1: BASIC INFORMATION
This section captures information regarding the reason you are submitting this application. Read this
section in full prior to indicating the reason for submission on page 4.
NEW ENROLLEES

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You are considered a new enrollee if you are:
• Enrolling in the Medicare program as a DMEPOS supplier for the first time under this tax
identification number.
• Enrolling in the Medicare program as a DMEPOS supplier but have a new tax identification number.
If you are reporting a change to your tax identification number, you must complete a new CMS 855S
enrollment application.
• A currently enrolled DMEPOS supplier that has come under new ownership. (Note: New owners
of existing DMEPOS suppliers must submit a dated bill of sale with an effective date of the
new ownership.)
EXISTING MEDICARE DMEPOS SUPPLIERS

Adding a New Location
If you are currently enrolled as a Medicare DMEPOS supplier and are applying to enroll a new business
location, you will need to complete a full CMS-855S application for the new location.

Reactivation
If your Medicare DMEPOS supplier billing number was deactivated, you may be required to either submit
an updated CMS-855S or certify to the accuracy of your enrollment information currently on file with the
NSC in order to reactivate billing privileges. (This differs from reenrollment: the NSC will contact you
when you need to reenroll.) You must also meet all current requirements for your supplier type, regardless
of how you were previously enrolled in the program.
Reenrollment
If you have been contacted by the NSC to reenroll, you will be required to either submit an updated
enrollment application or certify to the accuracy of the enrollment information currently on file with the
NSC. Do not submit this application until you have been contacted by the NSC.

Voluntary Termination
If you will no longer provide DMEPOS items or services to Medicare beneficiaries, you should voluntarily
terminate your enrollment in the Medicare program as a DMEPOS supplier.
Change of Information Other Than Adding a New Location
If you are adding, deleting, or changing information under your current Medicare supplier billing number. Any
change to your existing enrollment data must be reported within 30 days of the effective date of the change.
B. Check one box and provide effective date where requested:

CMS-855S (10/07)

SECTION 1: BASIC INFORMATION
A. Provide the two-letter State Code (e.g., TX for Texas) where your business is located

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B. Check one box and provide the necessary information where requested
DMEPOS suppliers must furnish their Medicare Identification Number, often referred to as a supplier
number, and their NPI below. Note: Each enrolled supplier of DMEPOS must obtain an NPI for each
practice location.

Medicare Identification Number(s) (if isssued):____________________ NPI:_____________________
REASON FOR APPLICATION

REQUIRED SECTIONS

❏ You are a new enrollee in Medicare

Complete all sections

❏ You are adding a new business location

Complete all sections

❏ You are reactivating your Medicare Supplier
Billing Number

Complete all sections

❏ You are reenrolling

Complete all sections

❏ You are voluntarily terminating your Medicare
enrollment.

1B, 13, and either 15 or 16

Effective date of termination

❏ You are changing your
Medicare information

CMS-855S (10/07)

Go to Section 1C

SECTION 1: BASIC INFORMATION

(Continued)

C. Check the item(s) listed that is changing and complete the applicable sections
MARK ALL THAT APPLY

REQUIRED SECTIONS

❏ Identifying Information
(NOTE: Including supplier type and/or
products and services)

1C, 2 (complete only those data elements
that are changing), 3, 13, and either 15 (if
you are the authorized official) or 16 (if
you are the delegated official), and 6 for
the signer if that authorized or delegated
official has not been established for this
DMEPOS supplier.

❏ Adverse Legal Actions/Convictions

1C, 3, 13, and either 15 (if you are the
authorized official) or 16 (if you are the
delegated official), and 6 for the signer if
that authorized or delegated official has not
been established for this DMEPOS supplier.

❏ Current Business Location

1C, 3, 4 (complete only those data elements
that are changing), 13, and either 15 (if you
are the authorized official) or 16 (if you are
the delegated official), and 6 for the signer
if that authorized or delegated official has not
been established for this DMEPOS supplier.

❏ Ownership and/or Managing Control Information
(Organizations)

1C, 3, 5, 13, and either 15 (if you are the
authorized official) or 16 (if you are the
delegated official), and 6 for the signer if
that authorized or delegated official has not
been established for this DMEPOS supplier.

❏ Ownership and/or Managing Control Information
(Individuals)

1C, 3, 6, 13, and either 15 (if you are the
authorized official) or 16 (if you are the
delegated official), and 6 for the signer if
that authorized or delegated official has not
been established for this DMEPOS supplier.

❏ Billing Agency Information

1, 3, 8 (complete only those data elements
that are changing), 13, and either 15 (if you
are the authorized official) or 16 (if you are
the delegated official), and 6 for the signer
if that authorized or delegated official has not
been established for this DMEPOS supplier.

❏ Authorized Official

1C, 3, 6, 13 and 15

❏ Delegated Official

1C, 3, 6, 13, 15 and 16

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CMS-855S (10/07)

SECTION 2: IDENTIFYING INFORMATION
SECTION 2A1 INSTRUCTIONS
A. SUPPLIER IDENTIFICATION
All applicants new to Medicare or suppliers that are making changes to their Medicare information
must complete this section. DO NOT PROVIDE BILLING AGENT INFORMATION HERE.

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1. Where should we mail your 1099?
Furnish the supplier’s legal business name (as reported to the IRS). A copy of the IRS CP-575 or other
correspondence issued by the IRS showing the tax identification number (TIN) for this business
MUST be submitted.
Legal Business Name as Reported to the IRS (NOT “Doing Business As” Name)

Tax Identification Number

1099 Mailing Address Line 1 (Street Name and Number)

Former Tax Identification Number (if changed)

1099 Mailing Address Line 2 (Suite, Room, etc.)

Medicaid Number (if applicable)

1099 Mailing Address City

1099 Mailing Address State

1099 Mailing Address ZIP Code + 4

2. Where Should Correspondence Be Mailed?
This is the address to which correspondence will be sent to you by the NSC and/or the DME MAC.
Business Location Name (NOT your billing agent, staffing company, or managing organization)
Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Suite, Room, etc.)
City/Town

Telephone Number

CMS-855S (10/07)

State

Fax Number (if applicable)

ZIP Code + 4

E-mail Address

(if applicable)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

3. Where Should We Mail Your Reenrollment Request Package if different from
Section 2A2 above?
This is the address to which the NSC will send your reenrollment request package.
Business Location Name (NOT your billing agent, staffing company, or managing organization)

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Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Suite, Room, etc.)
City/Town

Telephone Number

State

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

4. Is this supplier currently enrolled in the Medicare program other than as a
DMEPOS supplier?
❏ YES ❏ NO
If yes, please provide the following:
Medicare Contractor Name

Medicare Billing Number

NPI

B. TYPE OF SUPPLIER

The supplier must meet all Medicare requirements for the DMEPOS supplier type checked. Any specialty
personnel including, but not limited to, Registered Pharmacists, Respiratory Therapists, and
Orthotics/Prosthetics personnel, must be W-2 employees of the enrolling supplier.

Type of Supplier (Check all that apply)
❏ Ambulatory Surgical Center
❏ Department Store
❏ Grocery Store
❏ Home Health Agency
❏ Hospital
❏ Indian Health Service
❏ Intermediate Care Nursing Facility
❏ Medical Supply Company
❏ Medical Supply Company
with Orthotics Personnel
❏ Medical Supply Company
with Pedorthic Personnel
❏ Medical Supply Company
with Prosthetics Personnel
❏ Medical Supply Company
with Prosthetic/Orthotic Personnel
❏ Medical Supply Company
with Registered Pharmacist

CMS-855S (10/07)

❏ Medical Supply Company
with Respiratory Therapist
❏ Nursing Facility (other)
❏ Occupational Therapist
❏ Optician
❏ Optometrist
❏ Orthotics Personnel
❏ Oxygen Supplier
❏ Pedorthic Personnel
❏ Pharmacy
❏ Physical Therapist
❏ Physician
❏ Prosthetics Personnel
❏ Prosthetic/Orthotic Personnel
❏ Rehabilitation Agency
❏ Skilled Nursing Facility
❏ Other__________________________________

SECTION 2: IDENTIFYING INFORMATION

(Continued)

C. PRODUCTS AND SERVICES TO BE FURNISHED BY THIS SUPPLIER
Check all that apply. If you are a physician, skip to Section 2D. If you are adding/changing any supplies
for which you plan to bill, you must notify the NSC. Failure to do so could result in revocation and/or
overpayment collection.

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If you check “Parenteral Nutrition” or “Drugs/Pharmaceuticals,” a copy of the supplier’s State pharmacy
license must be submitted with this application.
❏ Accessories
❏ Patient Lifts and Seat Lift Mechanisms
❏ Commodes
❏ Power Mobility Devices (PMD)
❏ CPM Device
❏ Power Operated Vehicles (or scooters)
❏ Diabetic Equipment and Supplies
❏ Power Wheelchairs
❏ Diabetic Footwear
❏ Prosthetics
❏ Dialysis Equipment and Supplies
❏ Respiratory Equipment
❏ Drugs/Pharmaceuticals
❏ Bi-level Positive Airway Pressure
❏ Durable Medical Equipment
❏ Continuous Positive Airway Pressure
❏ Enteral Nutrition
❏ Intermittent Positive Pressure Breathing
❏ Heat/Cold Applications
❏ Invasive Mechanical Ventilation
❏ Hemodialysis Equipment and Supplies
❏ Speech Generating Device
❏ Hospital Beds
❏ Suction Pump
❏ Accessories
❏ Support Surfaces
❏ Electric
❏ For Beds
❏ Manual
❏ For Wheelchair/Power Mobility Devices
❏ Nebulizers
❏ Surgical Dressings
❏ Negative Pressure Wound
❏ Tens Units
❏ Optician
❏ Traction Equipment
❏ Orthotics – Custom Fabricated
❏ Urinals/Bedpans
❏ Orthotics – Non-customized
❏ Walkers, Canes and Crutches
❏ Oxygen
❏ Wheelchairs – Manual
❏ Parenteral Nutrition
❏ Other (Specify):__________________________
SECTION 2D INSTRUCTIONS: LIABILITY INSURANCE INFORMATION

Consistent with DMEPOS supplier standard 10 on page 31, all DMEPOS suppliers enrolling in Medicare
must have a comprehensive liability insurance policy in the amount of at least $300,000. The NSC must be
listed on the policy as a Certificate Holder. The insurance policy must remain in force at all times and provide
coverage of at least $300,000 per incident. Failure to maintain the required insurance at all times will result
in revocation of the Medicare supplier billing number, retroactive to the date the insurance lapsed.
Malpractice insurance policies do not demonstrate compliance with this requirement.

CMS-855S (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

D. LIABILITY INSURANCE INFORMATION
All DMEPOS suppliers must have liability insurance and must submit a complete copy of their liability
insurance policy or evidence of self-insurance with this application. You must provide the name and telephone
number for both your insurance agent and your underwriter. The underwriter is with the company providing
your insurance coverage. This contact information is necessary for the NSC to verify your policy. We will
not verify this information with your insurance agent.

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Name of Insurance Company
Insurance Policy Number

Date Policy Issued (mm/dd/yyyy)

Insurance Agent's First Name

Middle Initial

Agent’s Telephone Number

Agent’s Fax Number

Underwriter’s Agent's First Name

Middle Initial

Underwriter’s Telephone Number

Underwriter’s Fax Number

Expiration Date of Policy (mm/dd/yyyy)

Last Name

(if applicable)

Jr., Sr., etc.

Agent’s E-mail Address (if applicable).

Last Name

(if applicable)

Jr., Sr., etc.

Underwriter’s E-mail Address (if applicable)

Is the insurance agent also the underwriter for this policy?
❏ Yes (Submit written proof from the insurance company attesting the agent is also the underwriter.)
❏ No
E. INCORPORATION INFORMATION
Identify the type of organizational structure for this supplier (Check one):
❏ Corporation (regardless of whether supplier is “for-profit or “non-profit”)
❏ Partnership (“general” or “limited”)
❏ Sole Proprietor/Sole Proprietorship
❏ Other (Specify) ________________________________

F. ACCREDITATION INFORMATION
Note: Copy and complete this section if more than one accreditation needs to be reported.
Check one of the following and furnish any additional information as requested:
❏ The enrolling supplier is not accredited.
❏ The enrolling supplier, including the business location in Section 4A, is accredited.
Name of Accrediting Organization

Contact Person for the Accrediting Organization

Telephone Number of Contact Person

Date of Last Accreditation

Expiration of Current Accreditation

❏ The enrolling supplier, including the business location in Section 4A, is in the process of
obtaining accreditation.
Name of Accrediting Organization

Date Supplier Applied for Accreditation

CMS-855S (10/07)

SECTION 3: ADVERSE LEGAL ACTIONS/CONVICTIONS
This section captures information regarding adverse legal actions, such as convictions, exclusions, revocations,
and suspensions. All adverse legal actions must be reported, regardless of whether any records were
expunged or any appeals are pending. If you are uncertain as to whether a name reported on this application
has an adverse legal action, query the Healthcare Integrity and Protection Data Bank. For information on
how to access the Data Bank, call 1-800-767-6732 or visit www.npdb-hipdb.com. There is a charge for
using this service.

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ADVERSE LEGAL ACTIONS THAT MUST BE REPORTED

Convictions
1. The DMEPOS supplier, or any owner of the DMEPOS supplier was, within the last 10 years preceding
enrollment or revalidation of enrollment, convicted of a Federal or State felony offense that CMS has
determined to be detrimental to the best interests of the program and its beneficiaries. Offenses
include:
Felony crimes against persons and other similar crimes for which the individual was
convicted, including guilty pleas and adjudicated pre-trial diversions; financial crimes,
such as extortion, embezzlement, income tax evasion, insurance fraud and other similar
crimes for which the individual was convicted, including guilty pleas and adjudicated
pre-trial diversions; any felony that placed the Medicare program or its beneficiaries at
immediate risk (such as a malpractice suit that results in a conviction of criminal neglect
or misconduct); and any felonies that would result in a mandatory exclusion under
Section 1128(a) of the Social Security Act.
2. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or
service under Medicare or a State health care program, or (b) the abuse or neglect of a patient in
connection with the delivery of a health care item or service.
3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement,
breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health
care item or service.
4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with
or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section
1001.101 or 1001.201.
5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful
manufacture, distribution, prescription, or dispensing of a controlled substance.
Exclusions, Revocations, or Suspensions
1. Any revocation or suspension of a license to provide health care by any State licensing authority.
This includes the surrender of such a license while a formal disciplinary proceeding was pending
before a State licensing authority.
2. Any revocation or suspension of accreditation.
3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or
State health care program, or any debarment from participation in any Federal Executive Branch
procurement or non-procurement program.
4. Any current Medicare payment suspension under any Medicare billing number.
5. Any Medicare revocation of any Medicare billing number.

CMS-855S (10/07)

SECTION 3: ADVERSE LEGAL ACTIONS/CONVICTIONS (Continued)
ADVERSE LEGAL HISTORY
1. Have you or your organization, under any current or former name or business identity, ever had an
adverse legal action listed on page 10 of this application imposed against you/it?

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❏ YES–Continue Below

❏ NO–Skip to Section 4

2. If yes, report each adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the adverse legal action documentation(s) and resolution(s).
Adverse Legal Action

Date

Taken By

Resolution

____________________

___________________ ___________________ __________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

CMS-855S (10/07)

SECTION 4: CURRENT BUSINESS LOCATION
A. BUSINESS LOCATION INFORMATION
This section captures information regarding your business location.
• A separate application must be submitted for each physical business location that intends to bill
Medicare for items sold to Medicare beneficiaries from that location. Locations that serve only as
warehouses or repair facilities should not be reported.
• The address must be a specific street address as recorded by the United States Postal Service. Do not
furnish a P.O. Box. If you are in a hospital and/or other health care facility and you provide services
to patients at that facility, furnish the name and address of the hospital or facility.
• A change to the business location address requires submission of professional and business licenses
for the new address, and proof of insurance covering the new address.

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NOTE: You must separately enroll each Medicare DMEPOS supplier business location.

If you are making a change in this section, please check the box and list effective date below.

❏ CHANGE DATE

(mm/dd/yyyy)

Business Location Name (NOT your billing agent, staffing company, or managing organization)
Business Location Address Line 1 (Street Name and Number)
Business Location Address Line 2 (Suite, Room, etc.)
City/Town

Telephone Number

State

Fax Number (if applicable)

Date this Business Started at this Location (mm/dd/yyyy)

CMS-855S (10/07)

ZIP Code + 4

E-mail Address (if applicable)

Date this Business Terminated at this Location

(if applicable) (mm/dd/yyyy)

SECTION 4: CURRENT BUSINESS LOCATION (Continued)
Select the jurisdiction where the majority of claims for this location will be submitted. Claims submissions
are based on where the Medicare beneficiary resides.
❏ Jurisdiction A: Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts,
New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, or Vermont

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❏ Jurisdiction B: Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, or Wisconsin

❏ Jurisdiction C: Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi,
New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas,
Virgin Islands, Virginia, or West Virginia

❏ Jurisdiction D: Alaska, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri,
Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming,
Northern Mariana Islands, or American Samoa
List State(s) where you will provide items or services:
____________

____________

CMS-855S (10/07)

SECTION 4: CURRENT BUSINESS LOCATION (Continued)
B. WHERE DO YOU WANT REMITTANCE NOTICES OR SPECIAL PAYMENTS SENT?
Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT,
the “special payments” address below should indicate where all other payment information (e.g., remittance
notices, special payments) should be sent.

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NOTE: If you are already enrolled in Medicare and are not receiving Medicare payments via EFT, any
change to your enrollment information will require you to submit a CMS-588 application. All
future payments will then be received via EFT.

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

❏ “Special Payments” address is the same as the business location in Section 4A. Skip to Section 4C.
❏ “Special Payments” address is different than that listed in Section 4A. Provide address below.

NOTE: Payment will be made in the supplier’s “legal business name” shown in Section 2A1.
“Special Payments” Address Line 1

(PO Box or Street Name and Number)

“Special Payments” Address Line 2

(Suite, Room, etc.)

City/Town

State

ZIP Code + 4

B. WHERE DO YOU KEEP MEDICARE BENEFICIARY MEDICAL RECORDS?

CMS-855S (10/07)

SECTION 4: CURRENT PRACTICE LOCATION(S) (Continued)
C. WHERE DO YOU KEEP MEDICARE BENEFICIARY MEDICAL RECORDS?
If the Medicare beneficiaries’ medical records are stored at a location other than the location shown in
Section 4A, complete this section with the name and address of the storage location. This includes the
records for both current and former Medicare beneficiaries.

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Post office boxes and drop boxes are not acceptable as physical addresses where Medicare beneficiaries’
records are maintained. The records must be the supplier’s records, not the records of another supplier. If
all records are stored at the business location reported in Section 4A, please indicate below.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
First Medical Record Storage Facility (for current and former Medicare beneficiaries)
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

❏ Records are stored at the business location reported in Section 4A.
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, etc.)
City/Town

State

ZIP Code + 4

Second Medical Record Storage Facility (for current and former Medicare beneficiaries)
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, etc.)
City/Town

CMS-855S (10/07)

State

ZIP Code + 4

SECTION 5: OWNERSHIP INTEREST AND/OR
MANAGING CONTROL INFORMATION (ORGANIZATIONS)
NOTE – ONLY REPORT ORGANIZATIONS IN THIS SECTION. INDIVIDUALS MUST BE REPORTED
IN SECTION 6.
Complete this section with information about all organizations that have 5 percent or more (direct or indirect)
ownership interest of, any partnership interest in, and/or managing control of, the supplier identified in
Section 4A, as well as any information on adverse legal actions that have been imposed against that
organization. For examples of organizations that should be reported in this section, you should visit the
following Web site: www.cms.hhs.gov/Medicare ProviderSupEnroll. If there is more than one organization,
copy and complete this section for each.

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MANAGING CONTROL (ORGANIZATIONS)

Any organization that exercises operational or managerial control over the DMEPOS supplier, or conducts
the day-to-day operations of the DMEPOS supplier, is a managing organization and must be reported. The
organization need not have an ownership interest in the DMEPOS supplier in order to qualify as a managing
organization. For instance, it could be a management services organization under contract with the DMEPOS
supplier to furnish management services for this business location.
SPECIAL TYPES OF ORGANIZATIONS

Governmental/Tribal Organizations: If a Federal, State, county, city or other level of government, or
an Indian tribe, will be legally and financially responsible for Medicare payments received (including any
potential overpayments), the name of that government or Indian tribe should be reported as an owner. The
DMEPOS supplier must submit a letter on the letterhead of the responsible government (e.g., government
agency) or tribal organization that attests that the government or tribal organization will be legally and
financially responsible in the event that there is any outstanding debt owed to CMS. This letter must be
signed by an appointed or elected official of the government or tribal organization who has the authority to
legally and financially bind the government or tribal organization to the laws, regulations, and program
instructions of Medicare.

Indian Health Service Facilities: Special rules concerning insurance and licenses apply. Contact the
NSC concerning these rules.

Non-Profit, Charitable and Religious Organizations: Many non-profit organizations are charitable
or religious in nature, and are operated and/or managed by a Board of Trustees or other governing body.
The actual name of the Board of Trustees or other governing body should be reported in this section. While
the organization should be listed in Section 5, individual board members should be listed in Section 6.
Each non-profit organization should submit a copy of a 501(c)(3) document verifying its non-profit status.

CMS-855S (10/07)

SECTION 5: OWNERSHIP INTEREST AND/OR
MANAGING CONTROL INFORMATION (ORGANIZATIONS) (Continued)
All organizations that have any of the following must be reported:
• 5 percent or more ownership of the DMEPOS supplier,
• Managing control of the DMEPOS supplier, or
• A partnership interest in the DMEPOS supplier, regardless of the percentage of ownership the partner has.

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Owning/Managing organizations are generally one of the following types:
• Corporations (including non-profit corporations)
• Partnerships and Limited Partnerships (as indicated above)
• Limited Liability Companies
• Charitable and/or Religious organizations, or
• Governmental and/or Tribal organizations

If there is more than one organization, copy and complete this section for each.

A. ORGANIZATION WITH OWNERSHIP INTEREST AND/OR MANAGING
CONTROL—IDENTIFICATION INFORMATION

❏ Not Applicable

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

Check all that apply:

❏ 5 Percent or More Ownership Interest

❏ Partner

❏ Managing Control

Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)

Business Address Line 1 (Street Name and Number)
Business Address Line 2 (Suite, Room, etc.)
City/Town

State

ZIP Code + 4

Tax Identification Number (Required)

Medicare Identification Number(s) (if issued)

CMS-855S (10/07)

NPI (if issued)

SECTION 5:

OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION (ORGANIZATIONS) (Continued)

B. ADVERSE LEGAL HISTORY
If you are reporting a change to existing information, check “Change,” provide the effective date of the
change, and complete the appropriate fields in this section.
❏ Change
❏ Effective Date:__________________________
1. Has this organization in Section 5A above, under any current or former name or business identity,
ever had an adverse legal action listed on page 10 of this application imposed against it?

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❏ YES – Continue Below

❏ NO – Skip to Section 6

2. If YES, report each adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution.
Attach a copy of the adverse legal action documentation and resolution.
Adverse Legal Action

Date

Taken By

Resolution

____________________

___________________ ___________________ __________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

CMS-855S (10/07)

SECTION 6:

OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION (INDIVIDUALS)

NOTE: Only individuals should be reported in Section 6. Organizations must be reported in
Section 5. For more information on “direct” and “indirect” owners, go to
www.cms.hhs.gov/MedicareProviderSupEnroll.

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The supplier MUST have at least ONE owner and/or managing employee.

The following individuals must be reported in Section 6A:
• All persons who have a 5 percent or greater ownership (direct or indirect) interest in the DMEPOS
supplier.
• If (and only if) the DMEPOS supplier is a corporation (whether for-profit or non-profit), all
officers and directors of the DMEPOS supplier.
• All managing employees of the DMEPOS supplier.
• All individuals with a partnership interest in the DMEPOS supplier, regardless of the percentage
of ownership the partner has; and
• Authorized and delegated officials.

Example: A supplier is 100 percent owned by Company C, which itself is 100 percent owned by
Individual D. Assume that Company C is reported in Section 5A as an owner of the supplier. Assume
further that Individual D, as an indirect owner of the supplier, is reported in Section 6A1. Based on this
example, the suppler would check the “5 Percent or Greater Direct/Indirect Owner” box in Section 6A2.

NOTE: All partners within a partnership must be reported in this application. This applies to both
“General” and “Limited” partnerships. For instance, if a limited partnership has several limited
partners and each of them only has a 1 percent interest in the DMEPOS supplier, each limited
partner must be reported in this application, even though each owns less than 5 percent. The 5
percent threshold primarily applies to corporations and other organizations that are not partnerships.

For purposes of this application, the terms “officer,” “director,” and “managing employee” are defined
as follows:
• The term “Officer” is defined as any person whose position is listed as being that of an officer in
the DMEPOS supplier’s “articles of incorporation” or “corporate bylaws,” OR anyone who is
appointed by the board of directors as an officer in accordance with the DMEPOS supplier’s
corporate bylaws.
• The term “Director” is defined as a member of the DMEPOS supplier’s “board of directors.” It does
not necessarily include a person who may have the word “Director” in his/her job title (e.g.,
Departmental Director, Director of Operations).
• The term “managing employee” means a general manager, business manager, administrator, director,
or other individual who exercises operational or managerial control over, or who directly or indirectly
conducts, the day-to-day operations of the DMEPOS supplier, either under contract or through some
other arrangement, whether or not the individual is a W-2 employee of the DMEPOS supplier.
NOTE: If a governmental or tribal organization will be legally and financially responsible for Medicare
payments received (per the instructions for Governmental/Tribal Organizations in Section 5), the
supplier is only required to report its managing employees in Section 6. Owners, partners, officers,
and directors do not need to be reported.
CMS-855S (10/07)

SECTION 6:

OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION (INDIVIDUALS) (Continued)

Any information on adverse legal actions that have been imposed against the individuals reported in this
section must be furnished. If there is more than one individual, copy and complete this section for each
individual.
A. INDIVIDUALS WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL –
IDENTIFICATION INFORMATION

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If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

1. First Name

Middle Initial

Last Name

Social Security Number (Required)

Date of Birth (mm/dd/yyyy)

Medicare Identification Number (if issued)

NPI (if issued)

Jr., Sr., etc.

2. What is the above individual’s relationship with the supplier in Section 2A1? (Check all that apply.)
❏ 5 Percent or Greater Direct/Indirect Owner
❏ Director/Officer
(see Section 5 for definition)
❏ Contracted Managing Employee
❏ Partner
❏ Other _______________________________
❏ Managing Employee (W-2)
B. ADVERSE LEGAL HISTORY

Complete this section for the individual reported in Section 6A above.
If reporting a change to existing information, check “Change,” provide the effective date of the change,
and complete the appropriate fields in this section.
❏ Change

❏ Effective Date:__________________________

1. Has this individual listed in Section 6A, under any current or former name or business entity, ever had
an adverse legal action listed on page 10 of this application imposed against it?
❏ YES–Continue Below

❏ NO–Skip to Section 8

Date

Taken By

Resolution

____________________

___________________ ___________________ __________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

CMS-855S (10/07)

SECTION 7: FOR FUTURE USE

(This Section Not Applicable)

SECTION 8: BILLING AGENCY INFORMATION
A billing agency is a company or individual that you contract with to prepare and submit your claims. If
you use a billing agency, you are responsible for the claims submitted on your behalf.

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Check here ❏ if this section does not apply and skip to Section 13.
Billing Agency Name and Address

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

Legal Business/Individual Name as Reported to the Social Security Administration or Internal Revenue Service
Tax Identification Number or Social Security Number (required):
“Doing Business As” Name (if applicable)

Billing Agency Address Line 1 (Street Name and Number)
Billing Agency Address Line 2 (Suite, Room, etc.)
City/Town

Telephone Number

State

Fax Number (if applicable)

SECTION 9: FOR FUTURE USE

E-mail Address (if applicable)

(This Section Not Applicable)

SECTION 10: FOR FUTURE USE

(This Section Not Applicable)

SECTION 11: FOR FUTURE USE

(This Section Not Applicable)

SECTION 12: FOR FUTURE USE

(This Section Not Applicable)

CMS-855S (10/07)

ZIP Code + 4

SECTION 13: CONTACT PERSON
If questions arise during the processing of this application, the NSC will contact the individual shown
below. If no one is listed below, we will contact you directly.
❏ Contact the Authorized Official listed in Section 15.
❏ Contact the Delegated Official listed in Section 16.

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First Name

Middle Initial

Last Name

Jr., Sr., etc.

Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town

Telephone Number

CMS-855S (10/07)

State

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION
ON THIS ENROLLMENT APPLICATION
This section explains the penalties for deliberately furnishing false information in this
application to gain or maintain enrollment in the Medicare program.
1. 1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the
jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals
or covers up by any trick, scheme or device a material fact, or makes any false, fictitious, or fraudulent
statements or representations, or makes any false writing or document knowing the same to contain any
false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to
$250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of
up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain
derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.

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2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual
who, “knowingly and willfully,” makes or causes to be made any false statement or representation of
a material fact in any application for any benefit or payment under a Federal health care program. The
offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.
3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who:
a) knowingly presents, or causes to be presented, to an officer or any employee of the United
States Government a false or fraudulent claim for payment or approval;
b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false
or fraudulent claim paid or approved by the Government; or
c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of
damages sustained by the Government

4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including
an organization, agency or other entity) that knowingly presents or causes to be presented to an officer,
employee, or agent of the United States, or of any department or agency thereof, or of any State
agency…a claim…that the Secretary determines is for a medical or other item or service that the
person knows or should know:
a) was not provided as claimed; and/or
b) the claim is false or fraudulent.

This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an
assessment of up to three times the amount claimed, and exclusion from participation in the Medicare
program and State health care programs.

5. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care
benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or
device a material fact; or makes any materially false, fictitious, or fraudulent statements or representations,
or makes or uses any materially false fictitious, or fraudulent statement or entry, in connection with
the delivery of or payment for health care benefits, items or services. The individual shall be fined or
imprisoned up to 5 years or both.

CMS-855S (10/07)

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION
ON THIS ENROLLMENT APPLICATION (Continued)
6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute,
or attempt, to executive a scheme or artifice to defraud any health care benefit program, or to obtain,
by means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by or under the control of any, health care benefit program in connection with the delivery of
or payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up to
10 years or both. If the violation results in serious bodily injury, an individual will be fined or imprisoned
up to 20 years, or both. If the violation results in death, the individual shall be fined or imprisoned for
any term of years or for life, or both.

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7. The government may assert common law claims such as “common law fraud,” “money paid by
mistake,” and “unjust enrichment.”

Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the
unjust profit.

CMS-855S (10/07)

SECTION 15: CERTIFICATION STATEMENT
An AUTHORIZED OFFICIAL means an appointed official (for example, chief executive officer, chief
financial officer, general partner, chairman of the board, or direct owner) to whom the organization has
granted the legal authority to enroll it in the Medicare program, to make changes or updates to the
organization’s status in the Medicare program, and to commit the organization to fully abide by the
statutes, regulations, and program instructions of the Medicare program.

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A DELEGATED OFFICIAL means an individual who is delegated by an authorized official the authority to
report changes and updates to the supplier’s enrollment record. The delegated official must be an
individual with “ownership or control interest in” (as that term is defined in Section 1124(a)(3) of the
Social Security Act) or be a W-2 managing employee of the supplier.

Delegated officials may not delegate their authority to any other individual. Only an authorized official
may delegate the authority to make changes and/or updates to the supplier’s Medicare status. Even when
delegated officials are reported in this application, an authorized official retains the authority to make any
such changes and/or updates by providing his or her printed name, signature, and date of signature as
required in Section 15B.

NOTE: Authorized officials and delegated officials must be reported in Section 6 either on this application
or on a previous application to this same Medicare fee-for-service contractor. If this is the first
time an authorized and/or delegated official has been reported on the CMS-855S, you must
complete Section 6 for that individual.

By his/her signature, an authorized official binds the supplier to all of the requirements listed in the
Certification Statement and acknowledges that the supplier may be denied entry to or revoked from the
Medicare program if any requirements are not met. All signatures must be original and in ink. Faxed,
photocopied, or stamped signatures will not be accepted.

During the reenrollment process, either an authorized official or delegated official can sign the certification
statement.
By signing this application, an authorized official agrees to immediately notify the NSC if any information in
this application is not true, correct, or complete. In addition, an authorized official, by his/her signature,
agrees to notify the NSC of any future changes to the information contained in this application, after the
supplier is enrolled in Medicare, within 30 days of the effective date of the change.
The supplier can have as many authorized officials as it wants. If the supplier has more than two authorized
officials, it should copy and complete this section as needed.

Each authorized and delegated official must have and disclose his/her Social Security Number.

CMS-855S (10/07)

SECTION 15: CERTIFICATION STATEMENT

(Continued)

A. ADDITIONAL REQUIREMENTS FOR MEDICARE ENROLLMENT
These are additional requirements that the supplier must meet and maintain to bill the Medicare program.
Read these requirements carefully. By signing, the supplier is attesting to having read the requirements and
understanding them.

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By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in
Section 16 agree to adhere to the following requirements stated in this Certification Statement:

1. I agree to notify the NSC of any future changes to the information contained in this application within 30
days of the effective date of the change. I understand that any change in the business structure of this
supplier may require the submission of a new application.

2. I have read and understand the Penalties for Falsifying Information, as printed in this application. I
understand that any deliberate omission, misrepresentation, or falsification of any information contained
in this application or contained in any communication supplying information to Medicare, or any
deliberate alteration of any text on this application form, may be punished by criminal, civil, or
administrative penalties including, but not limited to, the denial or revocation of Medicare identification
number(s), and/or the imposition of fines, civil damages, and/or imprisonment.

3. I agree to abide by the Medicare laws, regulations and program instructions that apply to this supplier.
The Medicare laws, regulations, and program instructions are available through the Medicare contractor.
I understand that payment of a claim by Medicare is conditioned upon the claim and the underlying
transaction complying with such laws, regulations, and program instructions (including, but not limited
to, the Federal anti-kickback statute and the Stark law), and on the supplier’s compliance with all
applicable conditions of participation in Medicare.
4. Neither this supplier, nor any five percent or greater owner, partner, officer, director, managing employee,
authorized official, or delegated official thereof is currently sanctioned, suspended, debarred, or excluded
by the Medicare or State Health Care Program, e.g., Medicaid program, or any other Federal program,
or is otherwise prohibited from supplying services to Medicare or other Federal program beneficiaries.
5. I agree that any existing or future overpayment made to the supplier by the Medicare program may be
recouped by Medicare through the withholding of future payments.

6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare,
and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity.
7. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting
the Medicare program participation requirements, to release to any authorized representative, employee,
or agent of the Centers for Medicare & Medicaid Services (CMS) a copy of my most recent accreditation
survey, together with any information related to the survey that CMS may require (including corrective
action plans).

CMS-855S (10/07)

SECTION 15: CERTIFICATION STATEMENT

(Continued)

B. 1ST AUTHORIZED OFFICIAL SIGNATURE
I have read the contents of this application. My signature legally and financially binds this supplier to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete, and I authorize the NSC to verify this information.
If I become aware that any information in this application is not true, correct, or complete, I agree to notify
the NSC of this fact immediately.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

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CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

Authorized Official’s Information and Signature

First Name

Middle Initial

Last Name

Suffix (e.g., Jr., Sr.)

Telephone Number

Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)

Date Signed (mm/dd/yyyy)

C. 2ND AUTHORIZED OFFICIAL SIGNATURE
I have read the contents of this application. My signature legally and financially binds this supplier to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete, and I authorize the NSC to verify this information.
If I become aware that any information in this application is not true, correct, or complete, I agree to notify
the NSC of this fact immediately.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECK ONE

DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

Authorized Official’s Information and Signature

First Name

Middle Initial

Last Name

Suffix (e.g., Jr., Sr.)

Telephone Number

Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)

Date Signed (mm/dd/yyyy)

All signatures must be original and signed in ink. Applications with signatures deemed not
original will not be processed. Stamped, faxed or copied signatures will not be accepted.

CMS-855S (10/07)

SECTION 16: DELEGATED OFFICIAL(S) (OPTIONAL)
• You are not required to have a delegated official. However, if no delegated official is assigned, the
authorized official(s) will be the only person(s) who can make changes and/or updates to the supplier’s
status in the Medicare program.
• The signature of a delegated official shall have the same force and effect as that of an authorized official,
and shall legally and financially bind the supplier to the laws, regulations, and program instructions of
the Medicare program. By his or her signature, a delegated official certifies that he or she has read the
Certification Statement in Section 15 and agrees to adhere to all of the stated requirements. The delegated
official also certifies that he/she meets the definition of a delegated official. When making changes
and/or updates to the supplier’s enrollment information maintained by the Medicare program, the delegated official certifies that the information provided is true, correct, and complete.

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• A delegated official who is being deleted does not have to sign or date this application.

• Independent contractors are not considered “employed” by the supplier. Therefore, an independent
contractor cannot be a delegated official.

• The signature of an authorized official in Section 16 constitutes a legal delegation of authority to all
delegated official(s) assigned in Section 16.
• If there are more than two individuals, copy and complete this section for each individual.
A. 1ST DELEGATED OFFICIAL SIGNATURE

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECK ONE

DATE

❏ CHANGE

❏ ADD

(mm/dd/yyyy)

1. Delegated Official First Name
Print

Middle Initial

Last Name

Delegated Official (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Signature

❏

Check here if Delegated Official is a W-2 Employee

Suffix (e.g., Jr., Sr.)

Date Signed (mm/dd/yyyy)

Telephone Number

2. Authorized Official Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Signature

CMS-855S (10/07)

❏ DELETE

Date Signed (mm/dd/yyyy)

SECTION 16: DELEGATED OFFICIAL(S) (OPTIONAL)
B. 2ND DELEGATED OFFICIAL SIGNATURE
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

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CHECK ONE

DATE

❏ CHANGE

❏ ADD

(mm/dd/yyyy)

1. Delegated Official First Name
Print

Middle Initial

Last Name

Delegated Official (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Signature

❏

❏ DELETE

Check here if Delegated Official is a W-2 Employee

Suffix (e.g., Jr., Sr.)

Date Signed (mm/dd/yyyy)

Telephone Number

2. Authorized Official Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Signature

Date Signed (mm/dd/yyyy)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated to 6
hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
CMS-855S (10/07)

SECTION 17: SUPPORTING DOCUMENTS
This section lists the documents that, if applicable, must be submitted with this completed enrollment
application. If you are newly enrolling, adding a new location, reactivating or reenrolling, you must provide
all applicable documents. For changes, only submit documents that are applicable to the change requested. All
enrolling DMEPOS suppliers are required to furnish information on all Federal, State, and local professional
and business licenses, certifications, and/or registrations required to practice as a DMEPOS supplier in the
DMEPOS supplier’s State of business location as reported in Section 4A. Check the NSC website for further
guidance on supplier requirements. You are responsible for supplying and adhering to all required licensure/
certification, requirements, etc. for the supplies/services you provide.

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The enrolling DMEPOS supplier may submit a notarized Certificate of Good Standing from the DMEPOS
supplier’s business location’s State licensing/certification board or other medical associations, in lieu of
copies of the requested documents. This certification cannot be more than 30 days old.
If the enrolling DMEPOS supplier has had a previously revoked or suspended license, certification, or
registration reinstated, attach a copy of the reinstatement notice with this application.

MANDATORY
❏ Copy(s) of all Federal, State, and/or local (city/county) professional licenses, certifications
and/or registrations.
❏ Copy(s) of all Federal, State, and/or local (city/county) business licenses, certifications and/or registrations.
❏ Copy(s) of all liability insurance policies.
❏ Written confirmation from the IRS confirming your Tax Identification Number with the Legal
Business Name (e.g., IRS, CP 575) provided in Section 2. (NOTE: This information is needed if
the applicant is enrolling their professional corporation, professional association, or limited
liability corporation with this application or enrolling as a sole proprietor using an Employer
Identification Number.)
❏ Completed Form CMS-588, Authorization Agreement for Electronic Funds Transfer. Note: If a
supplier already receives payments electronically and is not making a change to its banking
information, the CMS-588 is not required.

MANDATORY, IF APPLICABLE
❏ Copy(s) of all adverse legal action documentation (e.g., notifications, resolutions, and reinstatement
letters).
❏ Copy(s) of all State pharmacy licenses
❏ Statement in writing from the bank. If Medicare payment due a supplier is being sent to a bank (or
similar financial institution) where the supplier has a lending relationship (that is, any type of loan),
then the supplier must provide a statement in writing from the bank (which must be in the loan
agreement) that the bank has agreed to waive its right of offset for Medicare receivables.
❏ Copy of delegated official’s W-2 if one has been designated.
❏ Copy of your bill of sale if you purchased an existing DMEPOS supplier with an active Medicare
supplier billing number.
❏ Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.

CMS-855S (10/07)

CMS MEDICARE DURABLE MEDICAL EQUIPMENT, PROSTHETICS,
ORTHOTICS, AND SUPPLIES (DMEPOS) SUPPLIER STANDARDS
Note: This list is an abbreviated version of the application certification standards that every Medicare DMEPOS supplier
must meet in order to obtain and retain their billing privileges. These standards, in their entirety, are listed in
42 C.F.R. pt. 424, sec 424.57(c) and were effective on December 11, 2000.
1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements.

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2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this
information must be reported to the National Supplier Clearinghouse within 30 days.
3. An authorized individual (one whose signature is binding) must sign the application for billing privileges.

4 A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items
necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare
program, any State health care programs, or from any other Federal procurement or nonprocurement programs.

5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical
equipment, and of the purchase option for capped rental equipment.

6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or
replace free of charge Medicare-covered items that are under warranty.
7. A supplier must maintain a physical facility on an appropriate site.

8. A supplier must permit CMS or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these
standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a
visible sign and posted hours of operation.
9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll
free number available through directory assistance. The exclusive use of a beeper, answering machine, or cell phone
is prohibited.

10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s
place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance
must also cover product liability and completed operations. Failure to maintain required insurance at all times will result in
revocation of the supplier’s billing privileges retroactive to the date the insurance lapsed.
11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard
prohibits suppliers from calling beneficiaries in order to solicit new business.

12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare-covered items, and maintain
proof of delivery.

13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts.
14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company,
Medicare-covered items it has rented to beneficiaries.
15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items
(inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item.

17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier.

18. A supplier must not convey or reassign a supplier number; i.e. the supplier may not sell or allow another entity to use its
Medicare Supplier Billing Number.

19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these
standards. A record of these complaints must be maintained at the physical facility.
20. Complaint records must include: the name, address, telephone number and health insurance claim number of the
beneficiary, a summary of the complaint, and any actions taken to resolve it.

21. A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations.

CMS-855S (10/07)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE SUPPLIER ENROLLMENT APPLICATION
PRIVACY ACT STATEMENT
The Centers for Medicare and Medicaid Services (CMS) is authorized to collect the information requested on this form by sections
1124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42 U.S.C. §§ 1320a-3(a)(1), 1320a-7,
1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt Collection Improvement Act [31 U.S.C. § 7701(c)].

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The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in
the Medicare program as suppliers of goods and services to Medicare beneficiaries and to assist in the administration of the
Medicare program. This information will also be used to ensure that no payments will be made to providers who are excluded
from participation in the Medicare program. All information on this form is required, with the exception of those sections
marked as “optional” on the form. Without this information, the ability to make payments will be delayed or denied.

The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS). The information
in this application will be disclosed according to the routine uses described below.

Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
2. A congressional office from the record of an individual health care provider in response to an inquiry from the
congressional office at the written request of that individual health care practitioner;
3. The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
4. Peer Review Organizations in connection with the review of claims, or in connection with studies or other review activities,
conducted pursuant to Part B of Title XVIII of the Social Security Act;
5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States
Government is a party to litigation and the use of the information is compatible with the purpose for which the agency
collected the information;
6. To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which criminal
penalties are attached;
7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique
Physician Identification Number Registry is unable to establish identity after matching contractor submitted data to the
data extract provided by the AMA;
8. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or
disability, or to the restoration or maintenance of health;
9. Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers of medical
services or to detect fraud or abuse;
10. State Licensing Boards for review of unethical practices or non-professional conduct;
11. States for the purpose of administration of health care programs; and/or
12. Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care
groups providing health care claims processing, when a link to Medicare or Medicaid claims is established, and data are
used solely to process supplier’s health care claims.
The supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) amended the
Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through computer matching.

Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this form is protected from public disclosure by
Federal law 5 U.S.C. § 552(b)(4) and Executive Order 12600.

Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this application (or attachments thereto) constitutes a trade secret or privileged or confidential information
(as such terms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal
nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then
such information will be protected from release by CMS under 5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.

CMS-855S (10/07)

File Type	application/pdf
File Modified	2007-09-25
File Created	2006-04-17