Cms-855a

Medicare Enrollment Application

CMS_855A_CHECK

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⚠️ Notice: This form may be outdated.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
INSTITUTIONAL PROVIDERS

CMS-855A

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 41 TO FIND A LIST OF THE SUPPORTING DOCUMENTATION THAT MUST BE
SUBMITTED WITH THIS APPLICATION.

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

Form Approved
OMB NO. 0938-0685

WHO SHOULD SUBMIT THIS APPLICATION
The following health care organizations must complete this application to initiate the enrollment process:

Community Mental Health Center
Hospital (all)

Comprehensive Outpatient
Indian Health Services Facility

Rehabilitation Facility
Organ Procurement Organization
Critical Access Hospital
Outpatient Physical Therapy / Occupational
End-Stage Renal Disease Facility
Therapy / Speech Pathology Services
Federally Qualified Health Center
Religious Non-Medical Health Care Institution
Histocompatibility Laboratory
Rural Health Clinic
Home Health Agency
Skilled Nursing Facility
Hospice
If your provider type is not listed above, contact the fee-for-service contractor before you submit this application.
Complete this application if you are a health care organization and you:
• Plan to bill Medicare for Part A medical services, or
• Would like to report a change to your existing Part A enrollment data. A change must be
reported within 90 days of the effective date of the change.
BILLING NUMBER INFORMATION
The Medicare Identification Number, often referred to as the Online Survey, Certification and Reporting
(OSCAR) number, is a generic term for any number other than the National Provider Identifier (NPI) that
is used by a provider to bill the Medicare program.
The NPI is the standard unique health identifier for health care providers and is assigned by the National
Plan and Provider Enumeration System (NPPES). Medicare healthcare providers, except organ procurement organizations, must obtain an NPI prior to enrolling in Medicare or before submitting a change
to your existing Medicare enrollment information. Applying for an NPI is a process separate from Medicare
enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov. As an organization
health care provider, it is your responsibility to determine if you have “subparts.” A subpart is a component
of an organization that furnishes healthcare and is not itself a legal entity. If you do have subparts, you
must determine if they should obtain their own unique NPIs. Before you complete this enrollment application,
you need to make those determinations and obtain NPI(s) accordingly.
IMPORTANT: For NPI purposes, sole proprietors and sole proprietorships are considered to be
“Type 1” providers. Organizations (e.g., corporations, partnerships) are treated as “Type 2” entities.
When reporting the NPI of a sole proprietor on this application, therefore, the individual’s Type 1
NPI should be reported; for organizations, the Type 2 NPI should be furnished.
For more information about subparts, visit www.cms.hhs.gov/NationalProvIdentStand to view the
“Medicare Expectations Subparts Paper.”
INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION
• Type or print all information so that it is legible. Do not use pencil.
• Report additional information within a section by copying and completing that section for each
additional entry.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your records.
• Send the completed application with original signatures and all required documentation to your
designated Medicare fee-for-service contractor.
CMS-855A (10/07)

AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should:
• Complete all required sections.
• Ensure that the legal business name shown in Section 2 matches the name on the tax documents.
• Ensure that the correspondence address shown in Section 2 is the provider’s address.
• Enter your NPI in the applicable section.
• Enter all applicable dates.
• Ensure that the correct person signs the application.
Note: A billing agent representative may not sign the application.
• Send your application and all supporting documentation to the designated fee-for-service contractor.
OBTAINING MEDICARE APPROVAL
The usual process for becoming a certified Medicare provider is as follows:
1. The applicant completes and submits a CMS-855A enrollment application and all supporting
documentation to its fee-for-service contractor.
2. The fee-for-service contractor reviews the application and makes a recommendation for approval or
denial to the CMS Regional Office, with a copy to the State agency.
3. The State agency conducts a survey. Based on the survey results, the State agency makes a recommendation
for approval or denial (a certification of compliance or noncompliance) to the CMS Regional Office.
Certain provider types may elect voluntary accreditation by a CMS-recognized accrediting organization in
lieu of a State survey.
4. The CMS Regional Office makes the final decision regarding program eligibility. The CMS Regional
Office also works with the Office of Civil Rights to obtain necessary Civil Rights clearances. If
approved, the provider must typically sign a provider agreement.
ADDITIONAL INFORMATION
For additional information regarding the Medicare enrollment process, visit
www.cms.hhs.gov/MedicareProviderSupEnroll.
The fee-for-service contractor 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 application will not be shared. It is protected under 5 U.S.C. Section
552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the
Privacy Act Statement.
MAIL YOUR APPLICATION
The Medicare fee-for-service contractor (also referred to as a fiscal intermediary or a Medicare administrative
contractor) that services your State is responsible for processing your enrollment application. To locate the
mailing address for your fee-for-service contractor, go to www.cms.hhs.gov/MedicareProviderSupEnroll.

CMS-855A (10/07)

SECTION 1: BASIC INFORMATION

NEW ENROLLEES

If you are:
• Enrolling with a particular fee-for-service contractor for the first time.
• Undergoing a change of ownership where the new owner will not be accepting assignment of the
Medicare assets and liabilities of the seller/former owner.

ENROLLED MEDICARE PROVIDERS
The following actions apply to Medicare providers already enrolled in the program:
Reactivation
To reactivate your Medicare billing privileges, submit this enrollment application. In addition, you must be
able to submit a valid claim and meet all current requirements for your provider type before reactivation
can occur.
Voluntary Termination
A provider should voluntarily terminate its Medicare enrollment when:
• It will no longer be rendering services to Medicare patients,
• It is planning to cease (or has ceased) operations,
• There has been an acquisition/merger and the new owner will not be using the identification number
of the entity it has acquired,
• There has been a consolidation and the identification numbers of the consolidating providers
will no longer be used, or
• There has been a change of ownership and the new owner will not be accepting assignment of the
Medicare assets and liabilities of the seller/former owner, meaning that the number of the seller/former
owner will no longer be used.
NOTE: A voluntary identification number termination cannot be used to circumvent any corrective action
plan or any pending/ongoing investigation, nor can it be used to avoid a period of reasonable
assurance, where a provider must operate for a certain period without recurrence of the deficiencies
that were the basis for the termination. The provider will not be reinstated until the completion of
the reasonable assurance period.
Change of Ownership (CHOW)
A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization.
The CHOW results in the transfer of the old owner’s identification number and provider agreement
(including any Medicare outstanding debt of the old owner) to the new owner. The regulatory citation for
CHOWs can be found at 42 C.F.R. 489.18. If the purchaser (or lessee) elects not to accept a transfer of the
provider agreement, then the old agreement should be terminated and the purchaser or lessee is considered
a new applicant.

CMS-855A (10/07)

SECTION 1: BASIC INFORMATION

(Continued)

Acquisition/Merger
An acquisition/merger occurs when a currently enrolled Medicare provider is purchasing or has been
purchased by another enrolled provider. Only the purchaser’s provider number and tax identification
number remain.
Acquisitions/mergers are different from CHOWs. In the case of an acquisition/merger, the seller/former
owner’s provider number dissolves. In a CHOW, the seller/former owner’s provider number typically
remains intact and is transferred to the new owner.
Consolidation
A consolidation occurs when two or more enrolled Medicare providers consolidate to form a new
business entity.
Consolidations are different from acquisitions/mergers. In an acquisition/merger, two entities combine
but the provider number and tax identification number (TIN) of the purchasing entity remains intact. In a
consolidation, the TINs and provider numbers of the consolidating entities dissolve and a new TIN and
provider number are assigned to the new, consolidated entity.
Because of the various situations in which a CHOW, acquisition/merger, or consolidation can
occur, it is recommended that the provider contact its fee-for-service contractor or its CMS
Regional Office if it is unsure as to whether such a transaction has occurred. The provider should
also review the applicable federal regulation at 42 C.F.R. 489.18 for additional guidance.

Change of Information
A change of information should be submitted if you are changing, adding, or deleting information under
your current tax identification number. Changes in your existing enrollment data must be reported to the
Medicare fee-for-service contractor in accordance with 42 C.F.R. 424.520(b).
NOTE: Ownership changes that do not qualify as CHOWs, acquisitions/mergers, or consolidations should
be reported here. The most common example involves stock transfers. For instance, assume that a
business entity’s stock is owned by A, B, and C. A sells his stock to D. While this is an ownership
change, it is generally not a formal CHOW under 42 C.F.R. 489.18. Thus, the ownership change
from A to D should be reported as a change of information, not a CHOW. If you have any
questions on whether an ownership change should be reported as a CHOW or a change of
information, contact your fee-for-service contractor or CMS Regional Office.
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.
Revalidation
CMS may require you to submit or update your enrollment information. The fee-for-service contractor will
notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation
application until you have been contacted by the fee-for-service contractor.

CMS-855A (10/07)

SECTION 1: BASIC INFORMATION

A. Check one box and complete the required sections
REASON FOR APPLICATION
❏ You are a new enrollee in Medicare

❏ You are enrolling with another fee-for-service
contractor’s jurisdiction
❏ You are reactivating your Medicare
enrollment

BILLING NUMBER INFORMATION

REQUIRED SECTIONS

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number in
Section 4.

Complete all sections except 2F, 2G,
and 2H

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number in
Section 4.

Complete all sections except 2F,
2G, and 2H

Effective Date of Termination:
❏ You are voluntarily terminating
your Medicare enrollment

Medicare Identification Number that
is terminating (if issued):

Complete sections:
1, 2B1, 13, and either 15 or 16

NPI (if issued):

❏ There has been a Change of Ownership
(CHOW) of the Medicare-enrolled provider

Medicare Identification
Number (if issued):
NPI:

You are the:
❏ Seller/Former Owner
❏ Buyer/New Owner

Tax Identification Number:
Medicare Identification Number of
the Seller/Former Owner (if issued):

❏ Your organization has taken part
in an Acquisition or Merger

NPI:

You are the:
❏ Seller/Former Owner
❏ Buyer/New Owner

Tax Identification Number:

❏ Your organization has Consolidated
with another organization
You are the:
❏ Former organization
❏ New organization

Medicare Identification Number of
the Seller/Former Owner (if issued):
NPI:
Tax Identification Number:

Seller/Former Owner:
1A, 2F, 13, and either 15 or 16
Buyer/New Owner:
Complete all sections except 2G and 2H

Seller/Former Owner:
1A, 2G, 13, and either 15 or 16
Buyer/New Owner:
1A, 2G, 4, 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 provider.

Former Organizations:
1A, 2H, 13, and either 15 or 16
New Organization:
Complete all sections except 2F and 2G

❏ You are changing your Medicare
information

Medicare Identification
Number (if issued):
NPI:

Go to Section 1B

❏ You are revalidating your Medicare
enrollment

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number in
Section 4.

Complete all sections except 2F, 2G,
and 2H

CMS-855A (10/07)

SECTION 1: BASIC INFORMATION

(Continued)

B. Check all that apply and complete the required sections:
REQUIRED SECTIONS

❏ Identifying Information

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

❏ Adverse Legal Actions/Convictions

1, 2B1, 3, 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.

❏ Practice Location Information, Payment Address
& Medical Record Storage Information

❏ Ownership Interest and/or Managing Control Information
(Organizations)

❏ Ownership Interest and/or Managing Control Information
(Individuals)

1, 2B1, 3, 4 (complete only those sections that are
changing), 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.
1, 2B1, 3, 5, 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.
1, 2B1, 3, 6, 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.

❏ Chain Home Office Information

1, 2B1, 3, 7, 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.

❏ Billing Agency Information

1, 2B1, 3, 8 (complete only those sections that are
changing), 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.

❏ Special Requirements for Home Health Agencies

1, 2B1, 3, 12, 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.

❏ Authorized Official(s)

1, 2B1, 3, 6, 13, and 15.

❏ Delegated Official(s) (Optional)

1, 2B1, 3, 6, 13, 15, and 16.

CMS-855A (10/07)

SECTION 2: IDENTIFYING INFORMATION

NEW ENROLLEES

Submit separate CMS-855A enrollment applications if the types of providers for which this
application is being submitted are separately recognized provider types with different rules regarding
Medicare participation. For example, if a provider functions as both a hospital and an end-stage renal
disease (ESRD) facility, the provider must complete two separate enrollment applications (CMS-855A)—
one for the hospital and one for the ESRD facility.
If a hospital performs multiple types of services, only one enrollment application (CMS-855A) is required.
For example, a hospital that has a swing-bed unit need only submit one enrollment application (CMS855A). This is because the provider is operating as a single provider type—a hospital—that happens to
have a distinct part furnishing different/additional services.
Special Enrollment Notes
● If you are adding a psychiatric or rehabilitation unit to a hospital, check the appropriate subcategory under the “Hospital” heading. (A separate enrollment for the psychiatric/rehabilitation unit is not
required). The unit should be listed as a practice location in Section 4.
●

If you are adding a home health agency (HHA) branch, list it as a practice location in Section 4. A
separate enrollment application is not necessary.

●

If you are changing hospital types (e.g., general hospital to a psychiatric hospital), indicate this in
Section 2. A new/separate enrollment is not necessary.

●

If you are adding an HHA sub-unit (as opposed to a branch), this requires an initial enrollment
application for the sub-unit.

●

If the hospital will focus on certain specialized services, the applicant should analyze whether the
facility will be a general hospital or will fall under the category of a specialty hospital. A specialty
hospital is defined as a facility that is primarily engaged in cardiac, orthopedic, or surgical care.
Based upon Diagnosis Related Group/Major Diagnosis Category (DRG/MDC) and type
(medical/surgical), the applicant should project all inpatient discharges expected in the first year of
the hospital’s operation. Those applicants that project that 45% or more of the hospital’s inpatient
cases will fall in either cardiac (MDC-5), orthopedic (MDC-8), or surgical care should check the
Hospital—Specialty Hospital block in Section 2A2.

CMS-855A (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

A. TYPE OF PROVIDER
The provider must meet all Federal and State requirements for the type of provider checked. Check only
one provider type. If the provider functions as two or more provider types, a separate enrollment application
(CMS-855A) must be submitted for each type.
1. Type of Provider (other than Hospitals –
See 2A2). Check only one:

❏ Community Mental Health Center
❏ Comprehensive Outpatient

Rehabilitation Facility

❏ Critical Access Hospital
❏ End-Stage Renal Disease Facility
❏ Federally Qualified Health Center
❏ Histocompatibility Laboratory
❏ Home Health Agency
❏ Home Health Agency (Sub-unit)
❏ Hospice
❏ Indian Health Services Facility
❏ Organ Procurement Organization
❏ Outpatient Physical Therapy/Occupational
Therapy/ Speech Pathology Services
❏ Religious Non-Medical Health Care Institution
❏ Rural Health Clinic
❏ Skilled Nursing Facility
❏ Other (Specify):_________________________

2. If this provider is a hospital, check all applicable
subgroups and units listed below and complete
Section 2A3.

❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏

Hospital—General
Hospital—Acute Care
Hospital—Children’s (excluded from PPS)
Hospital—Long-Term (excluded from PPS)
Hospital—Psychiatric (excluded from PPS)
Hospital—Rehabilitation (excluded from PPS)
Hospital—Short-Term (General and Specialty)
Hospital—Swing-Bed approved
Hospital—Psychiatric Unit
Hospital—Rehabilitation Unit
Hospital—Specialty Hospital

(cardiac, orthopedic, or surgical)

❏ Other (Specify):_________________________
3. Does this hospital have a compliance plan that
states that the hospital checks all managing
employees against the exclusion/debarment lists of
both the HHS Office of the Inspector General (OIG)
and the General Services Administration (GSA)?

❏ YES

❏ NO

B. IDENTIFICATION INFORMATION
1. BUSINESS INFORMATION

Legal Business Name (not the “Doing Business As” name) as reported to the Internal Revenue Service
Identify the type of organizational structure of this provider (Check one)
❏ Corporation ❏ Limited Liability Company ❏ Partnership ❏ Sole Proprietor

❏ Other (Specify):_____________________

Tax Identification Number

Incorporation Date (mm/dd/yyyy) (if applicable)

State Where Incorporated (if applicable)

Other Name
Type of Other Name
❏ Former Legal Business Name

CMS-855A (10/07)

❏ Doing Business As Name ❏ Other (Specify):___________________________________

SECTION 2: IDENTIFYING INFORMATION

(Continued)

2. STATE LICENSE INFORMATION/CERTIFICATION INFORMATION
Provide the following information if the provider has a State license/certification to operate as the
provider type for which you are enrolling.
❏ State License Not Applicable
License Number

State Where Issued

Effective Date (mm/dd/yyyy)

Expiration/Renewal Date (mm/dd/yyyy)

Certification Information
❏ Certification Not Applicable
Certification Number

State Where Issued

Effective Date (mm/dd/yyyy)

Expiration/Renewal Date (mm/dd/yyyy)

C. CORRESPONDENCE ADDRESS
Provide contact information for the entity listed in Section 2B1 of this section. Once enrolled, the information
provided below will be used by the fee-for-service contractor if it needs to contact you directly. This
address cannot be a billing agency’s address.
Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number

D. ACCREDITATION
Is this provider accredited?
If YES, complete the following:
Date of Accreditation (mm/dd/yyyy)

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

❏ YES ❏ NO
Name of Accrediting Body

Type of Accreditation or Accreditation Program (e.g., hospital accreditation program, home health accreditation)

E. COMMENTS
Use this section to clarify any information furnished in this section.

CMS-855A (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

F. CHANGE OF OWNERSHIP (CHOW) INFORMATION
Both the seller/former owner and the new owner should complete this section. (As the new owner may
not know all of the seller/former owner’s data, it should furnish this information on an “if known” basis.)
The seller/former owner must complete Sections 1A, 2F, 13, and either 15 or 16. (Section 6 must also
be completed if the signer has never completed Section 6 before.) The new owner must complete the
entire application.
Legal Business Name of “Seller/Former Owner” as reported to the Internal Revenue Service
“Doing Business As” Name of Seller/Former Owner (if applicable)

Old Owner’s Medicare Identification
Number (if issued)

Old Owner’s NPI

Name of Fee-For-Service Contractor
of Seller/Former Owner

Effective Date of Transfer
(this can be a future date)(MM/DD/YYYY)

Will the new owner be accepting assignment of the current “Provider Agreement?” ❏ YES ❏ NO
If the answer is “No,” then this is an initial enrollment and the new owner should follow the instructions
for “New Enrollees” in Section 1 of this form.
Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.
G. ACQUISITIONS/MERGERS
Effective Date of Acquisition

The seller/former owner need only complete Sections 1A, 2G, 13, and either 15 or 16; the new owner must
complete Sections 1A, 2G, 4, 13, and either 15 or 16. (Section 6 must also be completed if the signer has never
completed Section 6 before.)
1. PROVIDER BEING ACQUIRED
This section is to be completed with information about the currently enrolled provider that is being acquired
and will no longer retain its current Medicare provider number as a result of this acquisition.
Legal Business Name of the ”Provider Being Acquired” as reported to the Internal Revenue Service
Current Fee-for-Service Contractor

Provide the name and Medicare identification number of all units of the above provider that have separate
Medicare identification numbers but have not entered into separate provider agreements, such as swing bed
units of a hospital and HHA branches. Also furnish the NPI. Units that already have a separate provider
agreement should not be reported here.
Name/Department

Medicare Identification Number (if issued)

National Provider Identifier

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

CMS-855A (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

2. ACQUIRING PROVIDER
This section is to be completed with information about the organization acquiring the provider identified
in Section 2G1.
Legal Business Name of the “Acquiring Provider” as Reported
to the Internal Revenue Service

Medicare Identification
Number (if issued)

Current Fee-for-Service Contractor

National Provider Identifier

Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.
H. CONSOLIDATIONS
The newly formed provider completes the entire application. The providers that are being consolidated
are reported below.
1. 1ST CONSOLIDATING PROVIDER
This section is to be completed with information about the 1st currently enrolled provider that, as a
result of this consolidation, will no longer retain its current Medicare provider number.
Legal Business Name of the Provider Organization as Reported to the Internal Revenue Service
Current Fee-for-Service Contractor
Effective Date of Consolidation

Provide the name and Medicare identification number of all units of the above provider that have separate
Medicare identification numbers but have not entered into separate provider agreements, such as swing-bed
units of a hospital and HHA branches. Also furnish the NPI. Units that already have a separate provider
agreement should not be reported here.
Name/Department

Medicare Identification Number (if issued)

National Provider Identifier

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

2. 2ND CONSOLIDATING PROVIDER
This section is to be completed with information about the 2nd currently enrolled provider that, as a result
of this consolidation, will also no longer retain its current Medicare provider number.
Legal Business Name of the Provider Organization as Reported to the Internal Revenue Service
Current Fee-for-Service Contractor

CMS-855A (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

Provide the name and Medicare identification number of all units of the above provider that have separate

Medicare identification numbers but have not entered into separate provider agreements, such as swing-bed

units of a hospital and HHA branches. Also furnish the NPI. Units that already have a separate provider
agreement should not be reported here.
Name/Department

Medicare Identification Number (if issued)

National Provider Identifier

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

_________________________________

________________________________

3. NEWLY CREATED PROVIDER IDENTIFICATION INFORMATION
Complete this section with identifying information about the newly created provider resulting from
this consolidation.
Legal Business Name of the New Provider as Reported to the Internal Revenue Service Tax Identification Number

Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.

CMS-855A (10/07)

SECTION 3: ADVERSE LEGAL ACTIONS/CONVICTIONS

This section captures information on adverse legal actions, such as convictions, exclusions, revocations,
and suspensions. All applicable 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 an action falls within one of
the adverse legal action categories or 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.
ADVERSE LEGAL ACTIONS THAT MUST BE REPORTED
Convictions
1. The provider, supplier, or any owner of the provider or 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 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-855A (10/07)

SECTION 3: ADVERSE LEGAL ACTIONS/CONVICTIONS (Continued)
ADVERSE LEGAL HISTORY
1. Has your organization, under any current or former name or business entity, ever had an adverse action
listed on page 13 of this application imposed against it?
❏ 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-855A (10/07)

SECTION 4: PRACTICE LOCATION INFORMATION

INSTRUCTIONS
• Report all practice locations within the jurisdiction of the Medicare fee-for-service contractor to which
you will submit this application.
• If the provider is adding a practice location in the same State and the location requires a separate
provider agreement, a separate, complete CMS-855A must be submitted for that location. The location is
considered a separate provider for purposes of enrollment, and is not considered a practice location of the
main provider. If a provider agreement is not required, the location can be added as a practice location.
• If the provider is adding a practice location in another State and the location requires a separate
provider agreement, a separate, complete CMS-855A must be submitted for that location. (This often
happens when a home health agency wants to perform services in an adjacent State.)
• If the provider is adding a practice location within another fee-for-service contractor’s jurisdiction and
the provider is not already enrolled with that fee-for-service contractor, the provider must submit a full,
complete CMS-855A to that fee-for-service contractor—regardless of whether a separate provider
agreement is required. It cannot add the location as a mere practice location.
• Provide the specific street address as recorded by the United States Postal Service. Do not furnish a
P.O. Box.
IMPORTANT: The provider should list its primary practice location first in Section 4A. The
“primary practice location” must be associated with the NPI that the provider intends to use to bill
for Medicare services.
If you have any questions as to whether the practice location requires a separate State survey or provider
agreement, contact your fee-for-service contractor.
Community Mental Health Centers (CMHCs) must report all alternative sites where core services are
provided (proposed alternative sites for initial enrollment and actual alternative sites for those CMHCs
already participating in Medicare). In accordance with provisions of the Public Health Service Act, a
CMHC is required to provide mental health services principally to individuals who reside in a defined
geographic area (service area). Therefore, CMHCs must service a distinct and definable community. Those
CMHCs operating or proposing to operate outside this specific community must have a separate provider
agreement/number, submit a separate enrollment application, and individually meet the requirements to
participate. CMS will determine if the alternative site is permissible or whether the site must have a separate
agreement/number. CMS will consider the actual demonstrated transportation pattern of CMHC clients
within the community to ensure that all core services and partial hospitalization services are available from
each location within the community. A CMHC patient must be able to access and receive services he/she
needs at the parent CMHC site or the alternative site within the distinct and definable community served by
the parent.

CMS-855A (10/07)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
Hospitals must report all practice locations where the hospital provides services. Do not report separately
enrolled provider types such as skilled nursing facilities (SNFs), HHAs, RHCs, etc., even if these entities
are provider-based to the hospital. For instance, a hospital owns a SNF and an HHA. The hospital should
not list the SNF and HHA on its application, as they are not locations where the hospital furnishes services.
They are providers that are separate and distinct from the hospital, and will be reported on their respective
CMS-855A applications.
Base of Operations Address
• If this provider does not have a physical location where equipment and/or vehicles are stored or from
where personnel report on a regular basis, complete this section with information about the location
of the dispatcher/scheduler. This situation may occur if the provider operates mobile units that travel
continuously from one location directly to another.
• HHAs must complete this section.
Mobile Facility and/or Portable Units
To properly pay claims, Medicare must know when services are provided in a mobile facility or with
portable units. (This section is mostly applicable to providers that perform outpatient physical therapy,
occupational therapy, and speech pathology services.)
• A “mobile facility” is generally a mobile home, trailer, or other large vehicle that has been converted,
equipped, and licensed to render health care services. These vehicles usually travel to local shopping
centers or community centers to see and treat patients inside the vehicle.
• A “portable unit” is when the provider transports medical equipment to a fixed location (e.g., a
physician’s office or nursing home) to render services to the patient.

CMS-855A (10/07)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
A. PRACTICE LOCATION INFORMATION
Report all practice locations where services will be furnished. If there is more than one location, copy and
complete this section for each. Please list your primary practice location first.
To ensure that CMS establishes the correct associations between your Medicare legacy number (if issued) and
your NPI, you must list a Medicare legacy number—NPI combination for each practice location. If you have
multiple NPIs associated with both a single legacy number and a single practice location, please list below all
NPIs and associated legacy numbers for that practice location.
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)

Practice Location Name (“Doing Business As” name if different from Legal Business Name)
Practice Location Address Line 1 (Street Name and Number)—(Not a P.O. Box)
Practice Location Address Line 2 (Suite, Room, etc.)
City/Town

State

Telephone Number

ZIP Code + 4

Fax Number (if applicable)

E-mail Address (if applicable)

Medicare Identification Number (if issued)

National Provider Identifier

Medicare Identification Number (if issued)

National Provider Identifier

Medicare Identification Number (if issued)

National Provider Identifier

Medicare Identification Number (if issued)

National Provider Identifier

CLIA Number for this Location (if applicable)

FDA/Radiology (Mammography) Certification Number(s)
for this location (if applicable)

Hospitals and HHAs only (Identify type of practice location):
❏ HHA Branch
❏ Hospital Swing-Bed Unit
❏ Hospital Psychiatric Unit
❏ OPT Extension Site
❏ Hospital Rehabilitation Unit
❏ Other Hospital Practice Location:___________________________________

B. WHERE DO YOU WANT REMITTANCE NOTICES OR SPECIAL PAYMENTS SENT?
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)

Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT,
the “Special Payments” address will indicate where all other payment information (e.g., remittance notices,
special payments) are sent.
CMS-855A (10/07)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
❏ “Special Payments” address is the same as the practice location (only one address is listed in

Section 4A). Skip to Section 4C.

❏ “Special Payments” address is different than that listed in Section 4A, or multiple locations are listed.
Provide address below.
“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

C. WHERE DO YOU KEEP PATIENTS’ MEDICAL RECORDS?
If you store patients’ medical records (current and/or former patients) at a location other than the location
in Section 4A or 4D, complete this section with the address of the storage location.
If this section is not complete, you are indicating that all records are stored at the practice locations reported
in Section 4A or 4D. The records must be the provider’s records, not the records of another provider. Post
Office Boxes and drop boxes are not acceptable as physical addresses where patients’ records are maintained.
For mobile facilities/portable units, the patients’ medical records must be under the provider’s control.
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 Patients

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-855A (10/07)

State

ZIP Code + 4

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
Second Medical Record Storage Facility

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

State

ZIP Code + 4

D. BASE OF OPERATIONS ADDRESS FOR MOBILE OR PORTABLE PROVIDERS
(LOCATION OF BUSINESS OFFICE OR DISPATCHER/SCHEDULER)
The base of operations is the location from where personnel are dispatched, where mobile/portable
equipment is stored, and when applicable, where vehicles are parked when not in use.
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 here ❏ and skip to Section 4E if the “Base of Operations” address is the same as the
“Practice Location” listed in Section 4A.
Street Address Line 1 (Street Name and Number)
Street Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number

CMS-855A (10/07)

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
E. VEHICLE INFORMATION
If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish
the following vehicle information. Do not furnish information about vehicles that are used only to transport
medical equipment (e.g., when the equipment is transported in a van but is used in a fixed setting, such as
a doctor’s office) or ambulance vehicles. If more than three vehicles are used, copy and complete this section
as needed.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section. If you are a new enrollee, check “add.”
CHECK ONE FOR EACH VEHICLE
❏ CHANGE

❏ ADD

❏ DELETE

❏ ADD

❏ DELETE

❏ ADD

❏ DELETE

Type of Vehicle (van, mobile home, trailer, etc.)

Vehicle Identification Number

Effective Date:
❏ CHANGE
Effective Date:
❏ CHANGE
Effective Date:

For each vehicle, submit a copy of all health care related permits/licenses/registrations.
F. GEOGRAPHIC LOCATION FOR MOBILE OR PORTABLE PROVIDERS WHERE THE BASE
OF OPERATIONS AND/OR VEHICLE RENDERS SERVICES
For home health agencies (HHAs) and mobile/portable providers, furnish information identifying the
geographic area(s) where health care services are rendered.

NOTE: If you provide mobile health care services in more than one state and those states are serviced
by different Medicare fee-for-service contractors, complete a separate enrollment application
(CMS-855A) for each Medicare fee-for-service contractor’s jurisdiction.

1. INITIAL REPORTING AND/OR ADDITIONS
If you are reporting or adding an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.
❏ Entire State of __________________________
If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
City/Town

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
CMS-855A (10/07)

State

ZIP Code

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
20

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
2. DELETIONS
If you are deleting an entire State, it is not necessary to report each city/town. Simply check the box below
and specify the State.
❏ Entire State of __________________________
If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
City/Town

___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________
___________________________

CMS-855A (10/07)

State

ZIP Code

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 provider
identified in Section 2, as well as information on any adverse legal actions that have been imposed against
that organization. For examples of organizations that should be reported here, visit our Web site:
www.cms.hhs.gov/MedicareProviderSupEnroll. If there is more than one organization that should be
reported, copy and complete this section for each.
MANAGING CONTROL (ORGANIZATIONS)
Any organization that exercises operational or managerial control over the provider, or conducts the dayto-day operations of the provider, is a managing organization and must be reported. The organization need
not have an ownership interest in the provider in order to qualify as a managing organization. For instance,
it could be a management services organization under contract with the provider to furnish management
services for the business.
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
provider 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.
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.
All organizations that have any of the following must be reported in Section 5:
• 5 percent or more ownership (direct or indirect) of the provider,
• Managing control of the provider, or
• A partnership interest in the provider, regardless of the percentage of ownership the partner has.
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
• Governmental and/or Tribal organizations

CMS-855A (10/07)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION (ORGANIZATIONS) (Continued)
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)
Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town

State

ZIP Code + 4

Tax Identification Number (Required)
Medicare Identification Number(s) (if issued)

CMS-855A (10/07)

NPI (if issued)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION (ORGANIZATIONS) (Continued)
B. ADVERSE LEGAL HISTORY
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 organization in Section 5A, under any current or former name or business identity, ever had an
adverse legal action listed on page 13 of this application imposed against it?
❏ 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(s) and resolution(s).
Adverse Legal Action

Date

Taken By

Resolution

____________________

___________________ ___________________ __________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

CMS-855A (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.
The provider MUST have at least ONE owner and/or managing employee. If there is more
than one person listed in this section, copy and complete this section for each.
The following individuals must be reported in Section 6A:
• All persons who have a 5 percent or greater direct or indirect ownership interest in the provider;
• If (and only if) the provider is a corporation (whether for-profit or non-profit), all officers and
directors of the provider;
• All managing employees of the provider;
• All individuals with a partnership interest in the provider, regardless of the percentage of
ownership the partner has; and
• Authorized and delegated officials.
Example: A provider 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 provider. Assume
further that Individual D, as an indirect owner of the provider, is reported in Section 6A1. Based on this
example, the provider would check the “5 Percent or Greater Direct/Indirect Owner” box in Section 6A2.
NOTE: All partners within a partnership must be reported on 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 provider, each limited partner must
be reported on 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.
Non-Profit, Charitable or Religious Organizations: If you are a non-profit charitable or religious
organization that has no organizational or individual owners (only board members, directors or managers),
you should submit a 501(c)(3) document verifying non-profit status with your application.

CMS-855A (10/07)

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION (INDIVIDUALS) (Continued)
For purposes of this application, the terms “officer,” “director,” and “managing employee” are defined as follows:
Officer is any person whose position is listed as being that of an officer in the provider’s “articles of
incorporation” or “corporate bylaws,” or anyone who is appointed by the board of directors as an officer in
accordance with the provider’s corporate bylaws.
Director is a member of the provider’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).
Moreover, where a provider has a governing body that does not use the term “board of directors,” the
members of that governing body will still be considered “directors.” Thus, if the provider has a governing
body titled “board of trustees” (as opposed to “board of directors”), the individual trustees are considered
“directors” for Medicare enrollment purposes.
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 provider, either under contract or through some other arrangement, regardless
of whether the individual is a W-2 employee of the provider.
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
provider is only required to report its managing employees in Section 6. Owners, partners, officers,
and directors do not need to be reported, except those who are listed as authorized or delegated
officials on this application.

CMS-855A (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 in Section 6B.
A. INDIVIDUALS WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL –
IDENTIFICATION INFORMATION
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section. The name, date of birth, and social security number of
each person listed in this section must coincide with the individual’s information as listed with the Social
Security Administration.
CHECK ONE
DATE

❏ CHANGE

❏ ADD

❏ DELETE

(mm/dd/yyyy)

1. First Name
Social Security Number (Required)

Middle Initial

Last Name

Jr., Sr., etc.

Date of Birth (mm/dd/yyyy)

Medicare Identification Number (if issued) NPI (if issued)

2. What is the above individual’s relationship with the provider in Section 2B1? (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 you are changing information, check “change” box, furnish the effective date, and complete the
appropriate fields in this section.
❏ Change
❏ Effective Date:__________________________
1. Has the individual in Section 6A, under any current or former name or business identity, ever had an
adverse legal action listed on page 13 of this application imposed against him/her?
❏ YES–Continue Below

❏ NO–Skip to Section 7

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-855A (10/07)

SECTION 7: CHAIN HOME OFFICE INFORMATION

This section captures information regarding chain organizations. This information will be used to ensure
proper reimbursement when the provider’s year-end cost report is filed with the Medicare fee-for-service
contractor.
Chain organizations are generally defined as multiple providers that are owned, leased, or through any
other device, controlled by a single organization. The controlling organization is known as the chain
“home office.” Typically, the chain “home office”:
• Maintains uniform procedures in each facility for handling admissions, utilization review,

preparing and processing admission notices and bills, etc., and

• Maintains and centrally controls individual provider cost reports and fiscal records. In addition,
a major portion of the Medicare audit for each provider in the chain can be performed centrally
at the chain “home office.”
A few of the most common provider types that would typically be in a chain organization are hospitals,
comprehensive outpatient rehabilitation facilities, skilled nursing facilities, and home health agencies.
CHECK HERE ❏ IF THIS SECTION DOES NOT APPLY AND SKIP TO SECTION 8.

A. TYPE OF ACTION THIS PROVIDER IS REPORTING
Check one:
Effective Date

Sections to Complete

❏ Provider in chain is enrolling in Medicare for
____________
the first time (Initial Enrollment or Change of Ownership).

Complete all of Section 7.

❏ Provider is no longer associated with the chain
organization previously reported.

____________

Complete Section 7C, identifying
the former chain home office.

❏ Provider has changed from one chain to another.

____________

Complete Section 7 in full
to identify the new chain
home office.

❏ The name of provider’s chain home office is
changing (all other information remains the same).

____________

Complete Section 7C.

B. CHAIN HOME OFFICE ADMINISTRATOR INFORMATION
Name of Home Office
Administrator or CEO

First Name

Title of Home Office Administrator

CMS-855A (10/07)

Middle Initial

Last Name

Social Security Number

Jr., Sr., etc.
Date of Birth (mm/dd/yyyy)

SECTION 7: CHAIN HOME OFFICE INFORMATION (Continued)
C. CHAIN HOME OFFICE INFORMATION
1. Name of Home Office as Reported to the Internal Revenue Service
2. Home Office Business Street Address Line 1

(Street Name and Number)

Home Office Business Street Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

3. Home Office Tax Identification Number

Home Office Cost Report Year-End Date (mm/dd)

4. Home Office Fee-For-Service Contractor

Home Office Chain Number

D. TYPE OF BUSINESS STRUCTURE OF THE CHAIN HOME OFFICE
Check one:
Government:
Voluntary:
❏ Federal
❏ Non-Profit – Religious Organization
❏ Non-Profit – Other (Specify): ________________ ❏ State
❏ City
Proprietary:
❏ County
❏ Individual
❏ City-County
❏ Corporation
❏ Hospital District
❏ Partnership _____________________________ ❏ Other (Specify): __________________________
❏ Other (Specify): __________________________
E. PROVIDER’S AFFILIATION TO THE CHAIN HOME OFFICE
Check one:
❏ Joint Venture/Partnership
❏ Managed/Related
❏ Operated/Related
❏ Wholly Owned

CMS-855A (10/07)

❏ Leased
❏ Other (Specify): ____________

SECTION 8: BILLING AGENCY INFORMATION

Applicants that use a billing agency must complete this section. A billing agency is a company or individual
that you contract with to process and submit your claims. If you use a billing agency, you are responsible
for the claims submitted on your behalf.
❏ Check here if this section does not apply and skip to Section 12.
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)

CMS-855A (10/07)

ZIP Code + 4

SECTION 12: SPECIAL REQUIREMENTS FOR HOME HEALTH AGENCIES (HHAs)

INSTRUCTIONS
All HHAs and HHA sub-units enrolling in the Medicare program must complete this
section. HHAs and HHA sub-units initially enrolling in Medicare, Medicaid, or both programs on or
after January 1, 1998 are required to provide documentation supporting that they have sufficient initial
reserve operating funds (capitalization) to operate for the first three months in the Medicare and/or
Medicaid program(s). The capitalization requirement applies to all HHAs and HHA sub-units enrolling
in the Medicare program, including HHAs or HHA sub-units currently participating in the Medicare
program that, as a result of a change of ownership, will be issued a new provider number. The capitalization
requirement does not apply to a branch of an HHA. Regulations found at 42 C.F.R. 489.28 require that
the fee-for-service contractor determine the required amount of reserve operating funds needed for the
enrolling HHA or HHA sub-unit by comparing the enrolling HHA or HHA sub-unit to at least three
other new HHAs that it serves which are comparable to the enrolling HHA or HHA sub-unit. Factors to
be considered are geographic location, number of visits, type of HHA or HHA sub-unit and business
structure of the HHA or HHA sub-unit. The fee-for-service contractor then verifies that the enrolling
HHA or HHA sub-unit has the required funds. To assist the fee-for-service contractor in determining
the amount of funds necessary, the enrolling HHA or HHA sub-unit should complete this section.
CHECK HERE ❏ IF THIS SECTION DOES NOT APPLY AND SKIP TO SECTION 13.

A. TYPE OF HOME HEALTH AGENCY
1. CHECK ONE:
❏ Non-Profit Agency

❏ Proprietary Agency

2. PROJECTED NUMBER OF VISITS BY THIS HOME HEALTH AGENCY

How many visits does this HHA project it will make in the first: three months of operation?_____________
twelve months of operation? _______________
3. FINANCIAL DOCUMENTATION
A) In order to expedite the enrollment process, the HHA may attach a copy of its most current
savings, checking, or other financial statement(s) that verifies the initial reserve operating funds,
accompanied by:
1) An attestation from an officer of the bank or other financial institution stating that the funds are
in the account(s) and are immediately available for the HHA’s use, and
2) Certification from the HHA attesting that at least 50% of the reserve operating funds are
non-borrowed funds.
B) Will the HHA be submitting the above documentation with this application?
❏ YES ❏ NO
NOTE: The fee-for-service contractor may require a subsequent attestation that the funds are still available.
If the fee-for-service contractor determines that the HHA requires funds in addition to those indicated
on the originally submitted account statement(s), it will require verification of the additional
amount as well as a new attestation statement.

CMS-855A (10/07)

SECTION 12: SPECIAL REQUIREMENTS FOR HOME HEALTH AGENCIES (HHAs) (Continued)
4. ADDITIONAL INFORMATION
Provide any additional documentation necessary to assist the fee-for-service contractor or State agency
in properly comparing this HHA with other comparable HHAs. Use this space to explain or justify any
unique financial situations of this HHA that may be helpful in determining the HHA’s compliance with
the capitalization requirements.
B. NURSING REGISTRIES
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)

Does this HHA contract with a nursing registry whereby the latter furnishes personnel to perform HHA
services on behalf of the provider?
❏ YES–Furnish the information below
❏ NO–Skip to Section 13
Legal Business Name as Reported to the Internal Revenue Service
Tax Identification Number (required):
“Doing Business As” Name (if applicable)
Business Street Address Line 1 (Street Name and Number)
Business Street Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number

CMS-855A (10/07)

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

SECTION 13: CONTACT PERSON

If questions arise during the processing of this application, the fee-for-service contractor will contact the
individual shown below. If the contact person is an authorized or delegated official, check the appropriate
box below and skip to the section as indicated.
❏ Contact an Authorized Official listed in Section 15
❏ Contact an Delegated Official listed in Section 16
First Name
Telephone Number

Middle Initial

Last Name
Fax Number (if applicable)

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

State

ZIP Code + 4

E-mail Address

CMS-855A (10/07)

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION

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.
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-855A (10/07)

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION (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.
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-855A (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.
A DELEGATED OFFICIAL means an individual who is delegated by an authorized official the authority to
report changes and updates to the provider’s enrollment record. A delegated official must be an individual
with an “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 provider.
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 provider’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-855A, you must complete
Section 6 for that individual.
By his/her signature(s), an authorized official binds the provider to all of the requirements listed in the
Certification Statement and acknowledges that the provider 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.
Only an authorized official has the authority to sign (1) the initial enrollment application on behalf of the
provider or (2) the enrollment application that must be submitted as part of the periodic revalidation
process. A delegated official does not have this authority.
By signing this application, an authorized official agrees to immediately notify the Medicare fee-for-service
contractor if any information in the application is not true, correct, or complete. In addition, an authorized
official, by his/her signature, agrees to notify the Medicare fee-for-service contractor of any future changes
to the information contained in this form, after the provider is enrolled in Medicare, within 90 days of the
effective date of the change.
The provider can have as many authorized officials as it wants. If the provider 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-855A (10/07)

SECTION 15: CERTIFICATION STATEMENT

(Continued)

A. ADDITIONAL REQUIREMENTS FOR MEDICARE ENROLLMENT
These are additional requirements that the provider must meet and maintain in order to bill the Medicare
program. Read these requirements carefully. By signing, the provider is attesting to having read the
requirements and understanding them.
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 Medicare contractor of any future changes to the information contained in this
application in accordance with the time frames established in 42 C.F.R. § 424.520(b). I understand that
any change in the business structure of this provider 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 provider.
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 provider’s compliance with all
applicable conditions of participation in Medicare.
4. Neither this provider, 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 provider 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 I 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-855A (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 provider 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 Medicare fee-for-service
contractor 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 Medicare fee-for-service contractor 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

Title/Position

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 provider 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 Medicare fee-for-service
contractor 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 Medicare fee-for-service contractor 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

Title/Position

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-855A (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 provider’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 provider to the laws, regulations, and program instructions of
the Medicare program. By his or her signature, the 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 provider’s enrollment information maintained by the Medicare program, the
delegated official certifies that the information provided is true, correct, and complete.
• Delegated officials being deleted do not have to sign or date this application.
• Independent contractors are not considered “employed” by the provider and, therefore, cannot be
delegated officials.
• The signature(s) of an authorized official in Section 16 constitutes a legal delegation of authority to any
and 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)

Delegated Official First Name

Middle Initial

Last Name

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

❏

Check here if Delegated Official is a W-2 Employee

Suffix (e.g., Jr., Sr.)
Date Signed (mm/dd/yyyy)

Telephone Number

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

CMS-855A (10/07)

❏ DELETE

Date Signed (mm/dd/yyyy)

SECTION 16: DELEGATED OFFICIAL(S) (OPTIONAL)

(Continued)

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.
CHECK ONE
DATE

❏ CHANGE

❏ ADD

(mm/dd/yyyy)

Delegated Official First Name

Middle Initial

Last Name

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

❏

Check here if Delegated Official is a W-2 Employee

Suffix (e.g., Jr., Sr.)
Date Signed (mm/dd/yyyy)

Telephone Number

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

CMS-855A (10/07)

❏ DELETE

Date Signed (mm/dd/yyyy)

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, reactivating or revalidating your enrollment, you must provide all
applicable documents. For changes, only submit documents that are applicable to the change requested. The
enrolling provider may submit a notarized copy of a Certificate of Good Standing from the provider’s State
licensing/certification board or other medical associations in lieu of copies of the above-requested documents.
This certification cannot be more than 30 days old.
The fee-for-service contractor may request, at any time during the enrollment process, documentation to
support or validate information that you have reported in this application.
MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES
Required documents that can only be obtained after a State survey are not required as part of the application
submission but must be furnished within 30 days of the provider receiving them. The Medicare fee-forservice contractor will furnish specific licensing requirements for your provider type upon request.
❏ Licenses, certifications and registrations required by Medicare or State law.
❏ Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required
to operate a health care facility.
❏ Written confirmation from the IRS confirming your Tax Identification Number with the Legal
Business Name (e.g., IRS CP 575) provided in Section 2.
❏ Completed Form CMS-588, Authorization Agreement for Electronic Funds Transfer. Note: If a
provider already receives payments electronically and is not making a change to its banking
information, the CMS-588 is not required.
MANDATORY FOR SELECTED PROVIDER/SUPPLIER TYPES
❏ Copy(s) of all bills of sale or sales agreements (CHOWS, Acquisition/Mergers, and
Consolidations only).
❏ Copy(s) of all documents that demonstrate meeting capitalization requirements (HHAs only).
MANDATORY, IF APPLICABLE
❏ Statement in writing from the bank. If Medicare payment due a provider of services is being sent to a
bank (or similar financial institution) where the provider has a lending relationship (that is, any type of
loan), then the provider 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(s) of all adverse legal action documentation (e.g., notifications, resolutions, and reinstatement
letters).
❏ Copy of delegated official’s W-2 if you have designated one
❏ Copy of an attestation for government entities and tribal organizations
❏ Copy of HRSA Notice of Grant Award if that is a qualifying document for FQHC status

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 at 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 YOUR APPLICATION TO THIS ADDRESS.
CMS-855A (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)].
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 enrolling 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-855A (10/07)

File Type	application/pdf
File Title	Layout 1
File Modified	2008-08-01
File Created	2007-09-11