CMS-10220 Individual Enrollment Security Consent Form

Form Creation Date: [System Time Stamp] Security Consent Form ID: [System Generated]

Medicare Enrollment Security Consent Form

Individual Practitioner

Section 1 – Form Purpose and Instructions:

The purpose of this security consent form is for the Medicare provider to grant a third party (e.g. user group) access to its Medicare enrollment information which is maintained electronically in the CMS computer system referred to as the Provider Enrollment, Chain, and Ownership System (PECOS). By signing this form, the authorized official of the Medicare provider is confirming that the User Group Administrator listed in section 2B of this form is authorized to complete and submit provider enrollment information on behalf of that Medicare provider. The form was generated by an authorized user of PECOS. Additional information is available at www.cms.hhs.gov.

The completed form must be mailed to the CMS External User Services (EUS) identified in Section 5.

For the purposes of this form, the following definitions apply:

• Medicare Provider: An individual physician or non physician practitioner that submits claims to the Medicare Part A and/or Part B programs and provides Medicare-covered medical items and/or services to Medicare beneficiaries.

• User Group: A group of one or more individuals managing enrollment information on behalf of a Medicare provider and created by a User Group Administrator. The group is formed of authorized users of the CMS Internet Services as managed in the Individuals Authorized Access to the CMS Computer Services (IACS) system.

• User Group Administrator: An individual who registers in as a User Group Administrator and creates the user group associated to a Medicare provider within IACS. This person is trusted to approve the access requests of other users into the user group.

Section 2 – Authorization Statements:

PENALTIES FOR FALSIFYING INFORMATION ON THE MEDICARE SECURITY CONSENT FORM

The signatures below authorize the Medicare program to grant the provider or surrogate user group identified in Section 2B access to the Medicare enrollment information for the Medicare provider identified in Section 2A of this form. Both the Medicare provider and an administrator representing the provider or surrogate user group agree to the following statements:

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.

I, the undersigned, certify that I have read the contents of this form, and the information contained herein is true, correct, and complete. If I become aware that any information in this form is not true, correct, or complete, I agree to notify CMS External User Services of this fact immediately. In addition, I have read the Penalties for Falsifying Information, as printed in the Medicare Enrollment Security Consent Form. I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplied to Medicare or its contractors, or any deliberate alteration of any text on this form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of Medicare billing privileges and/or imposition of fines, civil damages, and/or imprisonment.

Medicare Enrollment Security Consent Form

Individual Practitioner

2A – Medicare Provider Identification Information:
Individual Practitioner’s Full Name (First, Middle, Last, Jr., Sr., M.D., D.O., etc): [1325] [1326] [1327] [1328]
Individual Practitioner’s Phone Number: (_____) ____________________________		NPI: [1726]
Individual Practitioner’s Signature: _______________________________________________________		Date Signed (MM/DD/YYYY): __________________________
2B – User Group Identification Information: Please select one of the listed user group administrators below to sign this form. All information in this section appears as listed in the Individuals Authorized Access to the CMS Computer Services (IACS) system for the identified user group.
Name/Legal Business Name: [Name/LBN]		SSN/TIN: [SSN/TIN]
User Group Administrator’s Full Name (First, Middle, Last, Jr., Sr., M.D., D.O., etc):
□ [User Group Administrator Name 1] □ [User Group Administrator Name 2] □ [User Group Administrator Name 3] □ [User Group Administrator Name 4] □ [User Group Administrator Name 5]	□ [User Group Administrator Name 6] □ [User Group Administrator Name 7] □ [User Group Administrator Name 8] □ [User Group Administrator Name 9] □ [User Group Administrator Name 10]
User Group Administrator Signature: _______________________________________________________		Date Signed (MM/DD/YYYY): __________________________
User Group Phone Number: [User Group Phone Number]

Medicare Enrollment Security Consent Form

Individual Practitioner

Section 3 – Security Consent Form Statements:

By signing this form, the Medicare provider identified in Section 2A agrees with the following statements.

The user group identified in Section 2B has the right to:

• View current and future Medicare application and enrollment data associated to the Medicare provider.

• Manage the Medicare providers enrollment data, including the ability to create, modify, and delete existing Medicare information and submit new Medicare applications.

• Grant/Deny other employees/members of the identified user group the rights to manage the Medicare providers enrollment data; The identified provider or surrogate user group accepts responsibility for an employees/members actions.

Section 4 – Security Consent Removal Statements:

By signing this form, the Medicare provider identified in Section 2A agrees with the following statements.

• I, the Medicare provider, am responsible for the removal of access to my Medicare application and existing Medicare enrollment data from the user group identified in Section 2B in the event the user group becomes inactive in my organization, group, or private practice.

• I, the Medicare provider, understand I may remove access to my Medicare information using the following methods:

• An individual Medicare practitioner can log on to the PECOS Website and remove a user group’s access.

• A PECOS Website user may submit a signed security consent form granting access to a new user group whereby access is automatically removed from the previous user group.

• A PECOS Website user can request the CMS EUS identified in Section 5 to remove a user group’s access.

Section 5 – Security Consent Form Mailing Instructions:

Please contact the CMS External User Services (EUS) should you have any questions regarding this Security Consent Form.

Please return the signed Security Consent Form to:

CMS External User Services (EUS)

PO Box 792750

San Antonio, Texas 78216

Phone Number: 1-866-484-8049

Form Type 1

2