Form CMS-855C Medicare Enrollment Application for Registration of Elig

Medicare Enrollment Application for Registration of Eligible Entities That Provide Health Insurance Coverage Complementary to Medicare Part B and Supporting Regulations

CMS-855C- 09112013

Change of Information

OMB: 0938-1233

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MEDICARE ENROLLMENT APPLICATION

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REGISTRATION FOR ELIGIBLE ENTITIES THAT PROVIDE HEALTH
INSURANCE COVERAGE COMPLEMENTARY TO MEDICARE
PART B AND PURSUANT TO 42 CFR § 424.66

CMS-855C

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

Form Approved
OMB No. xxxx-xxxx

WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION
This Medicare registration application is to be completed by all entities that provide health insurance coverage
complementary to Medicare Part B and intend to bill Medicare as an indirect payment procedure (IPP) biller
and the entity meets all Medicare requirements to submit claims using the indirect payment procedure. The
entity must furnish the name of at least one authorized official, preferably the administrator of the entity
providing the complementary health plan, who must sign this registration application attesting that the
registering entity meets the requirements to register as an indirect payment procedure entity and will also
abide by the requirements stated in the Certification & Attestation Statement in Section 10 of this application.
As stated in 42 CFR § 424.66, an entity must meet all of the following conditions to be eligible to submit claims
using the indirect payment procedure.
1. Provides coverage of the service under a complementary health benefit plan (this is, the coverage that
the plan provides is complementary to Medicare benefits and covers only the amount by which the Part B
payment falls short of the approved charge for the service under the plan).
2. Has paid the person who provided the service an amount (including the amount payable under the
Medicare program) that the person accepts as full payment.
3. Has the written authorization of the beneficiary (or of a person authorized to sign claims on his behalf
under § 424.36) to receive the Part B payment for the services for which the entity pays.

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4. Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement from
the beneficiary, his or her survivors or estate.
5. Submits any information CMS or the carrier may request, including an itemized physician or supplier bill, in
order to apply the requirements under the Medicare program.
6. Identifies and excludes from its requests for payment all services for which Medicare is the secondary payer.
If this registration is approved, the entity will be deemed eligible to submit claims to Medicare as an indirect
payment procedure biller.

The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4)
and/or (b)(6), respectively. See the Privacy Act Statement on the last page of this application.

GENERAL Instructions for completing this application
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All information on this form is required. If any information changes, it must be reported within 90 days.
Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred.
Complete all sections and include your other entity identifier (OEID) or health plan identifier (HPID).
Keep a copy of your completed Medicare registration application for your records.
Sign and date Section 11 of this application using blue ink.

NOTE: Medicare may request, at any time during the registration process, documentation to support and
validate information reported on this application. You are responsible for providing this documentation in a
timely manner, usually within 30 days.

ACRONYMS COMMONLY USED IN THIS APPLICATION
HPID: Health Plan Identifier
IPP: Indirect Payment Procedure
MAC: Medicare Administrative Contractor
NPI: National Provider Identifier
OEID: Other Entity Identifier

PTAN: Provider Transaction Account Number
SSN: Social Security Number
TIN: Tax Identification Number

*An Entity that successfully registers in the Medicare program may also be referred to as an “IPP Biller.”

CMS-855C (01/14)

SPECIFIC INSTRUCTIONS FOR COMPLETING EACH SECTION OF THIS APPLICATION
SECTION 1: BASIC INFORMATION
Check the appropriate box indicating the reason for
submitting this registration application.
SECTION 2: IDENTIFYING INFORMATION
A. Entity’s Identification Information
Furnish the legal business name and tax identification
number of the Entity/Organization that is providing
coverage of services under a complementary health benefits
plan to its members, in addition to the name of the health
plan and either the Entity’s OEID or the Health Plan’s HPID.
B. Resident Agent Name and Contact Information
If this entity has a Resident Agent, furnish complete contact
information for the agent.
C. Business Structure Information
Check the appropriate box indicating the Entity’s business
structure and when and where it is incorporated/registered
if applicable.
D. Internal Revenue Service Registration Information
Check the appropriate box as it applies to the Entity.

B. Final Adverse Legal Action History
Furnish any reportable final adverse legal actions that have
occurred against the organization reported in this section. If
there are no final adverse legal actions to report, check the
“NO” box.
SECTION 7: OWNERSHIP AND/OR MANAGING CONTROL
INFORMATION (INDIVIDUALS)
C. 1. Identifying Information: Furnish all requested
identifying information including any National Provider
Identifiers (NPIs) or Medicare Identification Numbers
(PTANs) of any individual(s) that have 5% or more
ownership or managing control of the Entity reported in
Section 2.
2. Title of Individual: Furnish the title of the individual
reported above.
3 & 4. Type of Ownership and Applicable Dates: Check
the appropriate box indicating the type of ownership
and when it occurred or ended as appropriate.
5 & 6. Type of Managing Control: Check the appropriate
box indicating the type of managing control and when
it occurred or ended as appropriate.
7. Authorized Official: Check the appropriate box
indicating if the individual will also be reported in
Section 11 as the authorized official of the Entity.

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SECTION 3: HEADQUARTERS ADDRESS AND CLAIMS
SUBMISSION INFORMATION
A. Headquarters Address Information
Furnish complete address information for the headquarters
or administrative/central office of the Entity providing the
complementary health benefits plan.

ownership or managing control of the Entity reported in
Section 2.
2 & 3. Type of Ownership and Applicable Dates: Check
the appropriate box indicating the type of ownership and
when it occurred or ended as appropriate.
4 & 5. Type of Managing Control: Check the appropriate
box indicating the type of managing control and when it
occurred or ended as appropriate.

B. States Where the Entity will Submit Claims
For each State where the registering entity will be
submitting claims, Medicare will issue a unique Medicare
billing number (PTAN). If services are rendered and a
claim submitted within a State that does not have a
corresponding PTAN, the claim will be denied. Check every
State and US Territory where the entity will be submitting
claims under the Indirect Payment Procedure (IPP). If
removing a previously reported State or Territory, check the
appropriate box. Also note that if a claim is not submitted
against an issued PTAN in a 12 month period, that specific
PTAN will be deactivated.
SECTION 4: IMPORTANT ADDRESS INFORMATION
A. Correspondence Mailing Address
Furnish a complete address and other contact information
where CMS or the MAC can get in direct contact with the
Administrator/Manager of the Health Plan. This address
may be the same as the Entity’s Headquarters address.
B. Remittance Notices/Special Payments Mailing Address
Furnish a complete mailing address where the Entity would
like to receive claims and payment related notices and nonroutine payments.
SECTION 5: FINAL ADVERSE LEGAL ACTIONS
As an Entity registering in the Medicare program to submit
claims and be reimbursed from the Medicare trust fund,
the Entity must complete this section. If there are no
final adverse legal actions to report you MUST check the
“NO” box.
SECTION 6: OWNERSHIP AND/OR MANAGING CONTROL
INFORMATION (ORGANIZATIONS)
A. 1. Identifying Information: Furnish all requested
identifying information including any National Provider
Identifiers (NPIs) or Medicare Identification Numbers
(PTANs) of the organization(s) that have 5% or more
CMS-855C (01/14)

D. Final Adverse Legal Action History
Furnish any reportable final adverse legal actions that have
occurred against the individual reported in this section. If
there are no final adverse legal actions to report, check the
“NO” box.
SECTION 8: BILLING AGENCY INFORMATION
If the Entity will use a billing agency to submit claims on its
behalf, furnish all requested information about the billing
agency/agent.
SECTION 9: CONTACT PERSON INFORMATION
If this entity does not have a resident agent, furnish a
contact person for CMS to contact if CMS has questions
regarding the information in this application.
SECTION 10: PENALTIES FOR FALSIFYING INFORMATION ON
THIS APPLICATION
Read and understand these penalties before signing and
submitting this application.
SECTION 11: AUTHORIZED OFFICIAL CERTIFICATION/
ATTESTATION STATEMENT & SIGNATURE
Read and understand the Certification/Attestation
statement before signing this application. This section lists
the conditions and requirements which must be met and
attested to in order to register in Medicare as an Entity
using the Indirect Payment Procedure for purposes of
Medicare claims reimbursement.
The Authorized Official must also be reported in Section 7
of the application.
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SECTION 1: BASIC INFORMATION
REASON FOR SUBMITTING THIS APPLICATION

Check one box and complete the sections of this application as indicated.
You are registering in Medicare as an indirect payment procedure
(IPP) biller

Complete all sections

You are currently registered in Medicare as an IPP biller and are
updating your information

Complete Section 2, all other
applicable sections and Section 11

You are voluntarily withdrawing your Medicare registration as an
IPP biller

Complete Section 2 and Section 11

SECTION 2: IDENTIFYING INFORMATION
A. ENTITY’S IDENTIFICATION INFORMATION
Legal Business Name of the Entity as reported to the IRS
Tax Identification Number (TIN)

Other Entity Identifier (OEID) (if issued)

Health Plan Identifier (HPID) (if issued)

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Name of Health Plan

B. RESIDENT AGENT NAME AND ADDRESS INFORMATION

If applicable, identify the Resident Agent for the registering Entity reported in Section 2A above.
If adding or removing a resident agent, check the applicable box and furnish the effective date.
Add

Remove

Effective Date (mm/dd/yyyy):

Resident Agent Legal Business Name

Middle Initial

Last Name

Jr., Sr., M.D., etc.

Resident Agent Name (First)

Resident Agent “Doing Business As” Name (if applicable)

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

Telephone Number

Fax Number (if applicable)

State

ZIP Code + 4

E-mail Address (if applicable)

C. ENTITY’S BUSINESS STRUCTURE INFORMATION
Identify the organizational structure for this Entity (Check one)
Corporation
Limited Liability Company
Partnership
Sole Proprietorship
Limited Partnership
Other (Specify):
Incorporation/Registration Date (mm/dd/yyyy) (if applicable)

Government-Owned Facility

State Where Incorporated/Registered (if applicable)

D. ENTITY’S INTERNAL REVENUE SERVICE REGISTRATION INFORMATION
Identify how the Entity is registered with the IRS. (Check one)
NOTE: If the Entity is a Federal and/or State government entity, indicate “Non-Profit.”
Proprietary
Non-Profit (If you check Non-Profit submit a copy of your IRS 501(c)(3).)

CMS-855C (01/14)

SECTION 3: Headquarters address and claims submission information
A. ENTITY’S HEADQUARTERS ADDRESS INFORMATION

Furnish the Entity’s physical address where the administrative office (headquarters) is located.
If you are reporting a change in this section, check the box below and furnish the effective date.
Change

Effective Date (mm/dd/yyyy):

Headquarters Location Name
Headquarters Location Street Address Line 1 (Street Name and Number – Not a P.O. Box)
Headquarters Location Street Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Telephone Number

Fax Number (if applicable)

ZIP Code + 4
E-mail Address (if applicable)

B. STATES WHERE THE ENTITY WILL SUBMIT CLAIMS

Check all States and Territories where the Entity will submit or cease submitting claims and the effective date.
Idaho

Montana

Puerto Rico

Add
Remove
Effective Date:

Alaska

Illinois

Nebraska

Rhode Island

Add
Remove
Effective Date:

American Samoa

Indiana

Nevada

South Carolina

Add
Remove
Effective Date:

Arizona

Iowa

New Hampshire

Add
Remove
Effective Date:

Arkansas

Kansas

California

Colorado

New Jersey

Tennessee

Add
Remove
Effective Date:

Kentucky

New Mexico

Texas

Add
Remove
Effective Date:

South Dakota

Add
Remove
Effective Date:

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Alabama

Louisiana

New York

Utah

Add
Remove
Effective Date:

Connecticut

Maine

North Carolina

Vermont

Add
Remove
Effective Date:

Delaware

Maryland

North Dakota

Virginia

Add
Remove
Effective Date:

District of Columbia

Massachusetts

Northern Marianas Islands

Virgin Islands

Add
Remove
Effective Date:

Florida

Michigan

Ohio

Washington

Add
Remove
Effective Date:

Georgia

Minnesota

Oklahoma

West Virginia

Add
Remove
Effective Date:

Guam

Mississippi

Oregon

Wisconsin

Add
Remove
Effective Date:

Hawaii

Missouri

Pennsylvania

Wyoming

Add
Remove
Effective Date:

CMS-855C (01/14)

SECTION 4: IMPORTANT ADDRESS INFORMATION
A. CORRESPONDENCE MAILING ADDRESS

This is the address where correspondence will be sent to you by the MAC, OR
Check

here if you want all Correspondence mailed to your Headquarters Location Address in Section 3 and
skip this section.

If you are reporting a change in this section, check the box below and furnish the effective date.
Change

Effective Date (mm/dd/yyyy):

Location Name
Attention (optional)
Mailing Address Line 1 (P.O. Box or Street Name and Number)
Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Fax Number (if applicable)

E-mail Address (if applicable)

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Telephone Number (if applicable)

ZIP Code + 4

B. REMITTANCE NOTICES/SPECIAL PAYMENTS MAILING ADDRESS

Medicare will issue all routine payments via electronic funds transfer (EFT). Since payment will be made
via EFT, the special payments address below should indicate where all other payment information (e.g.,
remittance notices, non-routine special payments) should be sent, OR
here if your Remittance Notices/Special Requests should be mailed to your Headquarters Location
Address in Section 3 and skip this section, OR
Check here if your Remittance Notices/Special Requests should be mailed to your Correspondence Mailing
Address in Section 4A and skip this section.

Check

NOTE: If you are a new enrollee, you must submit an EFT Authorization Agreement (CMS-588) with this
application. If you need to make changes to your current EFT Authorization Agreement (CMS-588), contact
your MAC.

Change

If you are reporting a change in this section, check the box below and furnish the effective date.
Effective Date (mm/dd/yyyy):

NOTE: Payments will be made in the Entity’s legal business name as shown in Section 2A.
Special Payments Address Line 1 (PO Box or Street Name and Number)
Special Payments Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

CMS-855C (01/14)

State

ZIP Code + 4

SECTION 5: FINAL ADVERSE LEGAL ACTIONS
This section captures information regarding final adverse legal actions that have been taken against the IPP
Entity such as convictions, exclusions, revocations and suspensions. All final adverse legal actions listed below
must be reported, regardless of whether any records were expunged or any appeals are pending.

A. CONVICTIONS

1. Any federal or State felony conviction within the ten years preceding registration.
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 CFR § 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.

B. EXCLUSIONS, REVOCATIONS OR SUSPENSIONS

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1. Any revocation or suspension of a license to provide health care or health care insurance 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 nonprocurement program.
4. Any past or current Medicare payment suspension under any Medicare billing number.
5. Any Medicare revocation of any Medicare billing number.

C. FINAL ADVERSE LEGAL ACTION HISTORY
Change

If you are reporting a change in this section, check the box below and furnish the effective date.
Effective Date (mm/dd/yyyy):

1. Has this entity, under any current or former name or business identity, ever had a final adverse legal action
listed in Section 5A or 5B above imposed against it?
YES–Continue Below
NO–Skip to Section 6
2. If yes, report each final 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 relevant final legal adverse action documents.
FINAL ADVERSE LEGAL ACTION

CMS-855C (01/14)

DATE

TAKEN BY

RESOLUTION

SECTION 6: OWNERSHIP AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS)
Report all organizations that have 5% or greater ownership and/or managing control of the Entity reported in
Section 2A.

A. ORGANIZATION IDENTIFICATION INFORMATION (OWNERSHIP AND/OR MANAGING CONTROL)
Check here if this section is not applicable for the Entity reported in Section 2A, and skip to Section 7.

If you need to report more than one owning/managing organization, copy and complete this page for each.
If you are changing, adding, or removing ownership or managing control information, check the applicable
box, furnish the effective date, and complete the appropriate fields in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

1. Complete all identifying information below.
Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Business Address Line 1 (Street Name and Number)
Business Address Line 2 (Suite, Room, Apt. #, etc.)
State

ZIP Code + 4

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City/Town
Tax Identification Number (Required)

National Provider Number (NPI) (if issued)

Medicare Identification Number (PTAN) (if issued)

Telephone Number

Fax Number (if applicable)

E-mail Address (if applicable)

2. What is the above organization’s ownership interest in the Entity reported in Section 2A?
5% or Greater Direct/Indirect Owner
Partnership Interest
Wholly Own

3. What is the effective date the above organization acquired and/or ended the above ownership interest?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):

4. What is the above organization’s managing control of the Entity reported in Section 2A?
(Check all that apply)
Managing Organization
Governing Body
Wholly Operate
Controlling Entity
Board of Trustees
5. What is the effective date the above organization acquired and/or ended the above managing control?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):

B. FINAL ADVERSE LEGAL ACTION HISTORY

Complete this section for each organization reported in Section 6A.
If you are reporting a new final adverse legal action, check the box below and furnish the effective date.
New

Effective Date (mm/dd/yyyy):

1. Has the organization in Section 6A above, under any current or former name or business identity, ever had
a final adverse legal action listed in Section 5 of this application imposed against it?
YES–Continue Below
NO–Skip to Section 7
2. If YES, report each final 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 relevant final adverse legal action document(s).
FINAL ADVERSE LEGAL ACTION

CMS-855C (01/14)

DATE

TAKEN BY

RESOLUTION

SECTION 7: OWNERSHIP AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)
Report all individuals who have 5% or greater ownership and/or managing control of the Entity in Section 2A
including the Resident Agent and Other Administrators of the Complementary Health Plan.

A. INDIVIDUAL IDENTIFICATION INFORMATION (OWNERSHIP AND/OR MANAGING CONTROL)
If you need to report more than one individual, copy and complete this section for each.

If you are changing, adding, or removing ownership or managing control information, check the applicable
box, furnish the effective date, and complete the appropriate fields in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

1. Complete all identifying information below.
First Name

Middle Initial

Last Name

Jr., Sr., M.D., etc.

Social Security Number (Required)

Date of Birth (mm/dd/yyyy)

Medicare Identification Number (PTAN) (if issued)

National Provider Number (NPI) (if issued)

Telephone Number

E-mail Address (if applicable)

Fax Number (if applicable)

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2. What is the above individual’s title?

3. What is the above individual’s ownership interest in the Entity reported in Section 2A?
5% or Greater Direct/Indirect Owner
Partner
4. What is the effective date the above individual acquired and/or ended the above ownership interest?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):

5. What is the above individual’s managing control of the Entity reported in Section 2A?
(Check all that apply)
Officer
Contracted Managing Employee
Appointed/Elected Official
Director
W-2 Managing Employee
Administrator
6. What is the effective date the above individual acquired and/or ended the above managing control?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):
7. Is the above individual also an Authorized Official reported in Section 11?

Yes

B. FINAL ADVERSE LEGAL ACTION HISTORY

Complete this section for each individual reported in Section 7A.
If you are reporting a new final adverse legal action, check the box below and furnish the effective date.
New

Effective Date (mm/dd/yyyy):

1. Has the individual reported in Section 7A above, under any current or former name or business entity, ever
had a final adverse legal action listed in Section 5 of this application imposed against them?
YES–Continue Below
NO–Skip to Section 8
2. If YES, report each final 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 relevant final adverse legal action document(s).
FINAL ADVERSE LEGAL ACTION

CMS-855C (01/14)

DATE

TAKEN BY

RESOLUTION

SECTION 8: BILLING AGENCY INFORMATION
A billing agency/agent is a company or individual that the Entity contracts with to prepare and submit claims.
If the Entity uses a billing agency/agent it must complete this section. Even if it uses a billing agency/agent, it is
responsible for the accuracy of claims submitted on its behalf.
Check here if this section does not apply and skip to Section 9.

BILLING AGENCY NAME AND ADDRESS

If you are changing information, or adding or removing a billing agency, check the applicable box, furnish the
effective date, and complete the appropriate fields in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

Legal Business Name as reported to the Internal Revenue Service or Individual Name as Reported to the Social Security Administration
If Individual Billing Agent, Date of Birth (mm/dd/yyyy)
Billing Agency Tax Identification Number or Billing Agent Social Security Number (required)
Billing Agency “Doing Business As” Name (if applicable)

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

State

Telephone Number

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)
Billing Agency/Agent Other Entity Identifier (OEID) (if issued)

Billing Agency/Agent Medicare Identification Number (PTAN) (if issued)

SECTION 9: CONTACT PERSON INFORMATION

First Name

If questions arise during the processing of this application, CMS will attempt to contact your resident agent. If
you do not have a resident agent, CMS will contact the individual reported below.
Middle Initial

Last Name

Jr., Sr., M.D., etc.

Contact Person Address Line 1 (Street Name and Number)
Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

Relationship or Affiliation to You (Spouse, Secretary, Attorney, Billing Agent, etc.)

CMS-855C (01/14)

SECTION 10: PENALTIES FOR FALSIFYING INFORMATION ON THIS APPLICATION
Read and understand these penalties before signing and submitting this application.
This section explains the penalties for deliberately furnishing false information in this application to gain or
maintain registration in the Medicare program.
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 entities 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:

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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;
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
entity, 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.

5. 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.
6. 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.
7. 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.
8. 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-855C (01/14)

SECTION 11: AUTHORIZED OFFICIAL CERTIFICATION/ATTESTATION STATEMENT AND
SIGNATURE
Read and understand the Certification/Attestation statement before signing this application. This section lists
the conditions and requirements which must be met and attested to in order to register in Medicare as an
Entity using the Indirect Payment Procedure for Medicare claims reimbursement.
The Authorized Official must also be reported in Section 7 of this application. A Resident Agent cannot be an
authorized official unless they are also 5% or greater owners of the Entity reported in Section 2A.
You MUST sign and date Section 11B of this certification statement in order to be registered in the
Medicare program. In doing so, you are attesting to meeting and maintaining the Medicare requirements
stated below.
An AUTHORIZED OFFICIAL means an appointed official (for example, administrator, chief executive officer,
chief financial officer, or chairman of the board) to whom the Entity has granted the legal authority to
register it in the Medicare program, to make changes or updates to the Entity’s registration information in
the Medicare program, and to commit the Entity to fully abide by the statutes, regulations, and program
instructions of the Medicare program.
By his/her signature, an authorized official binds the Entity to all of the conditions and requirements listed
in the Certification/Attestation Statement and acknowledges that the Entity may be denied registration in
the Medicare program or have its registration revoked if any conditions or requirements are not met. All
signatures must be original and in blue ink. Faxed, photocopied, or stamped signatures will not be accepted.

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By signing this application, the authorized official agrees to immediately notify Medicare if any information
in the application is not true, correct, or complete. In addition, the authorized official, by his/her signature,
agrees to notify Medicare of any future changes to the information contained in this application within
90 days. All applications must be signed by an authorized official or they will be rejected.
The certification/attestation in Section 11A includes the requirements and conditions the Entity must meet
and maintain to bill Medicare using the indirect payment procedure. Read these requirements and conditions
carefully. By signing Section 11B, you are attesting to having read the requirements and conditions and
understanding them.

Your signature further stipulates that you agree to adhere to all of the requirements listed below and
acknowledge that this Entity may be denied registration or have its registration revoked if any requirements
and conditions are not met.

CMS-855C (01/14)

SECTION 11: AUTHORIZED OFFICIAL CERTIFICATION/ATTESTATION STATEMENT AND
SIGNATURE (Continued)
A. Certification/Attestation Statement

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Under penalty of perjury, I, the undersigned, certify to the following:
1. I have read the contents of this application, and the information contained herein is true, correct and
complete. If I become aware that any information in this application is not true, correct and complete, I
agree to notify Medicare of this immediately.
2. I agree to notify Medicare of any current or future changes to the information contained in this application
within 90 days of the change.
3. 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 and/ or administrative
penalties including, but not limited to, the imposition of fines, civil damages and/or imprisonment.
4. I agree to abide by the Social Security Act and all applicable Medicare laws, regulations and program
instructions that apply to this Entity, including all of the conditions of 42 CFR § 424.66. The Medicare laws,
regulations, and program instructions are available through Medicare. 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 this Entity’s compliance with the conditions of 42 CFR § 424.66 below:
a) Provides coverage of the service under a complementary health benefit plan (this is, the coverage that
the plan provides is complementary to Medicare benefits and covers only the amount by which the
Part B payment falls short of the approved charge for the service under the plan).
b) Has paid the person who provided the service an amount (including the amount payable under the
Medicare program) that the person accepts as full payment.
c) Has the written authorization of the beneficiary (or of a person authorized to sign claims on his
behalf under § 424.36) to receive the Part B payment for the services for which the Entity pays.
d) Relieves the beneficiary of liability for payment for the service and will not seek any reimbursement
from the beneficiary, his or her survivors or estate.
e) Submits any information CMS or the carrier may request, including an itemized physician or supplier
bill, in order to apply the requirements under the Medicare program.
f) Identifies and excludes from its requests for payment all services for which Medicare is the secondary
payer.
5. Neither this Entity or the authorized official is currently sanctioned, suspended, debarred, or excluded by
Medicare or any State health care program (e.g., Medicaid program), or any other Federal program, or is
otherwise prohibited from participating in Medicare or other Federal programs.
6. I agree that any existing or future overpayment made to the Entity by the Medicare program may be
recouped by Medicare through the withholding of future Medicare payments.
7. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare,
and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity.

B. AUTHORIZED OFFICIAL SIGNATURE(S)

If you are adding or removing an Authorized Official, check the applicable box and furnish the effective date.
Add
Remove
Effective Date (mm/dd/yyyy):
Authorized Official Attestation
I have read the contents of this application and the certification/attestation statement in Section 11A. My
signature legally and financially binds this Entity 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 MAC to verify this information.
Authorized Official Name and Signature
First Name (Print)
Telephone Number

Middle Initial

Last Name

E-mail Address (if applicable)

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

Jr., Sr., M.D., etc.
Title/Position
Date Signed (mm/dd/yyyy)

All signatures must be original and signed in blue ink. Applications with signatures deemed not original
or not dated will not be processed. Stamped, faxed or copied signatures will not be accepted.
CMS-855C (01/14)

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

MEDICARE REGISTRATION PRIVACY ACT STATEMENT
The information collected here will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
The Authority for maintenance of the system is given under provisions of sections 1102(a) (Title 42 U.S.C. 1302(a)),
1128 (42 U.S.C. 1320a–7), 1814(a)) (42 U.S.C. 1395f(a)(1), 1815(a) (42 U.S.C. 1395g(a)), 1833(e) (42 U.S.C. 1395I(3)),
1871 (42 U.S.C. 1395hh), and 1886(d)(5)(F), (42 U.S.C. 1395ww(d)(5)(F) of the Social Security Act; 1842(r) (42 U.S.C.
1395u(r)); section 1124(a)(1) (42 U.S.C. 1320a–3(a)(1), and 1124A (42 U.S.C. 1320a–3a), section 4313, as amended, of
the BBA of 1997; and section 31001(i) (31 U.S.C. 7701) of the DCIA (Pub. L. 104–134), as amended.
PECOS will collect information provided by an applicant related to identity, qualifications, practice locations,
ownership, billing agency information, reassignment of benefits, electronic funds transfer, the NPI and related
organizations. PECOS will also maintain information on business owners, chain home offices and provider/chain
associations, managing/ directing employees, partners, authorized and delegated officials, supervising physicians
of the supplier, ambulance vehicle information, and/or interpreting physicians and related technicians. This system
of records will contain the names, social security numbers (SSN), date of birth (DOB), and employer identification
numbers (EIN), national provider identifier (NPI), other entity identifier (OEID) and health plan identifier (HPID)
for each disclosing entity, owners with 5 percent or more ownership or control interest, as well as managing/
directing employees. Managing/directing employees include general manager, business managers, administrators,
directors, and other individuals who exercise operational or managerial control over the provider/ supplier. The
system will also contain Medicare identification numbers (i.e., CCN, PTAN, OEID, HPID and the NPI), demographic
data, professional data, past and present history as well as information regarding any adverse legal actions such as
exclusions, sanctions, and felonious behavior.

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The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used
for a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure
of data is known as a “routine use.” The CMS will only release PECOS information that can be associated with
an individual as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both
identifiable and non-identifiable data may be disclosed under a routine use. CMS will only collect the minimum
personal data necessary to achieve the purpose of PECOS. Below is an abbreviated summary of the six routine
uses. To view the routine uses in their entirety go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/
PrivacyActSystemofRecords/Systems-of-Records-Items/CMS023307.html.

1. To support CMS contractors, consultants, or grantees, who have been engaged by CMS to assist in the
performance of a service related to this collection and who need to have access to the records in order to
perform the activity.
2. To assist another Federal or state agency, agency of a state government or its fiscal agent to:
a. Contribute to the accuracy of CMS’s proper payment of Medicare benefits,
b. Enable such agency to administer a Federal health benefits program that implements a health benefits
program funded in whole or in part with federal funds, and/or
c. Evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance
operations.
3. To assist an individual or organization for research, evaluation or epidemiological projects related to the
prevention of disease or disability, or the restoration or maintenance of health, and for payment related
projects.
4. To support the Department of Justice (DOJ), court or adjudicatory body when:
a. The agency or any component thereof, or
b. Any employee of the agency in his or her official capacity, or
c. Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the
employee, or
d. The United States Government, is a party to litigation and that the use of such records by the DOJ, court or
adjudicatory body is compatible with the purpose for which CMS collected the records.
5. To assist a CMS contractor that assists in the administration of a CMS administered health benefits program, or
to combat fraud, waste, or abuse in such program.
6. To assist another Federal agency to investigate potential fraud, waste, or abuse in, a health benefits program
funded in whole or in part by Federal funds.
The applicant 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.
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-xxxx. The time required to complete this
information collection is estimated to be 1 hour per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
CMS-855C (01/14)

File Type	application/pdf
File Modified	2013-11-08
File Created	2013-09-11