Crosswalk_JA 03212013

Crosswalk for Changes Section 1011 PROVIDER ENROLLMENT APPLICATION (CMS-10115)

Section # on Current CMS-10115 (07/05)	Type of Change	Rational for Change
HEADER OF FORM	Change: Directions for completion of this form begin on page 3.	To reflect correct page number
BLOCK 1.	Move: Make block go the entire length of page	Allows ample room for legal business name of provider
Block 2.	Move: Make block go the entire length of page	Allows ample room for DBA name of provider
Block 3.	Move: Make block go the entire length of page	Allows ample room for physical address of provider
Block 4.	Move: Make block go the entire length of page	Allows ample room for name, phone number and address of contact person
Block 9.	Move: Make block go the entire length of page	Allows ample room for reporting applicant type
Block 10.	Move: Make block go the entire length of page	Allows ample room for reporting identification numbers
Block 11.	Change: Close parenthesis on note in second check box	Correction of typo
Block 14.	Change: Insert page break directly after block 14	Allows all information provider is agreeing to by signing the form to be on one page
ALL PROVIDERS	Move: Move the verbiage under “ALL PROVIDERS” to page 2	Allows all information provider is agreeing to by signing the form to be on one page
HOSPITALS ONLY	Move: Move the verbiage under “HOSPITALS ONLY” to page 2	Allows all information provider is agreeing to by signing the form to be on one page
ATTENTION: READ THE FOLLOWING PROVISION OF FEDERAL LAW CAREFULLY BEFORE SIGNING	Move: Move the verbiage under “ATTENTION” to page 2	Allows all information provider is agreeing to by signing the form to be on one page
BLOCK 15.	Move: Move block 15 to page 2	Allows name of authorized official and all information provider is agreeing to by signing the form to be on one page
BLOCK 16.	Move: Move block 16 to page 2	Allows telephone number of signer and all information provider is agreeing to by signing the form to be on one page
BLOCK 17.	Move: Move block 16 to page 2	Allows signature and all information provider is agreeing to by signing the form to be on one page
BLOCK 18.	Move: Move block 16 to page 2	Allows signature date and all information provider is agreeing to by signing the form to be on one page
APPLICATION DEFINITIONS and INSTRUCTIONS	Move: Move to page 3	Allows for instructions to be on a separate page so providers do not need to print them; saves paper
APPLICATION DEFINITIONS and INSTRUCTIONS	Change: Section 1011 Enrollment Application and Section 1011 Program should be capitalized in the first sentence	Correction of typos
APPLICATION SUBMISSION	Change: Change name and address of contractor	Allows for update to current CMS contractor handling the Section 1011 Program enrollment function
APPLICATION INSTRUCTIONS: Box 9	Move: Move to page 3	Allows for instructions to be on a separate page so providers do not need to print them; saves paper
FOOTER	Change: Version number “Form CMS -10115 (04/12)	To reflect updated version number of form