Summary of Changes

SUMMARY OF CHANGES TO THE FEDERAL REIMBURSEMENT OF EMERGENCY HEALTH SERVICES FURNISHED TO UNDOCUMENTED ALIENS (SECTION 1011) PROVIDER ENROLLMENT APPLICATION

(CMS FORM #10115, OMB FORM #0938-0929)

December 18, 2007

1. TOP OF PAGE: Add checkboxes to allow the completer to indicate the function they are trying to accomplish with the form, i.e., submit a new application (“New Application,” change provider’s information (“Change Request,”) or terminate from the program (“Voluntary Termination”).

2. Remove existing wording, “Date Submitted.”

3. BOX 1: Revise the wording of “APPLICANT’S LEGAL BUSINESS NAME,” to read, “Applicant's Legal Business Name as Reported to the IRS and Individual Physician Name when applicant is Physician in Box 9.”

4. BOX 3: Revise the wording “Address,” to read, “Physical Address.”

5. BOX 5: Add a new box to break out the provider’s “County” from the address box.

6. BOX 6: Add a new box to indicate the provider’s email address.

7. BOX 9: Add the option for the provider to select an additional provider Type of “Physician Group,” and direct the provider to complete the appropriate attachments.

8. BOX 10: Add the requirement for the provider to supply additional provider identifiers, physician social security number (SSN), and National Provider Identifier number (NPI).

9. BOX 12: Clarify the requirement for the provider to supply the name, Medicare number and NPI number of each hospital where the physician has privileges by adding that wording to the box. Add the option for the provider to select “Physician Group Privileges,” and direct the provider to complete the appropriate attachments.

10. BOX 15: Revise the wording from “Type Name and Title of Authorized Representative,” to “Write Name and Title of Authorized Official.”

11. Updated the instruction page to incorporate the changes to the form and generally, clarify what is being requested on the application.

12. Updated the attachments to mirror the changes to the form.