Form CMS-855POH Annual Report of Physician-Owned Hospital Ownership and/

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ANNUAL REPORT OF PHYSICIAN-OWNED

HOSPITAL OWNERSHIP AND/OR

INVESTMENT INTEREST

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CMS-855POH

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

Form Approved

OMB No. 0938-xxxx

ANNUAL REPORT OF PHYSICIAN-OWNED HOSPITAL

OWNERSHIP AND/OR INVESTMENT INTEREST

In accordance with section 1877(i)(1)(C)(i) of the Social Security Act (the Act), physician-owned hospitals that
seek to comply with the whole hospital or rural provider exceptions to the physician self-referral law must
submit an annual report containing a detailed description of specific ownership and investment information.
Physician-owned hospitals will satisfy the above reporting requirement by completing the relevant fields
below on an annual basis.
If the information submitted in this report has not changed since it was last reported to CMS by the
hospital, check this box and complete Section 1, Section 4 (if there is a new Contact Person), and Section 5.

SECTION 1: IDENTIFYING INFORMATION OF THE PHYSICIAN-OWNED HOSPITAL

PHYSICIAN-OWNED HOSPITAL IDENTIFICATION INFORMATION
Furnish the Legal Business Name, TIN, NPI and CCN of the Physician-Owned Hospital whose ownership and/or
investment interest is being reported.

National Provider Number (NPI)

Medicare Identification Number (CCN) (if issued)

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Tax Identification Number (TIN)

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Legal Business Name as reported to the Internal Revenue Service (not the “Doing Business As” name)

DEFINITION OF TERMS USED IN THIS REPORT

Ownership or investment interest means an interest in an entity through equity, debt, or other means, and
includes an interest in an entity that holds an ownership or investment interest in any entity that furnishes
designated health services, as defined in 42 C.F.R. § 411.351. It does not include an interest that satisfies the
requirements at 42 C.F.R. 411.356(a) or (b).

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Physician means a doctor of medicine or osteopathy, a doctor of dental surgery or dental medicine, a doctor
of podiatric medicine, a doctor of optometry, or a chiropractor, as defined in section 1861(r) of the Social
Security Act. A physician and the professional corporation of which he or she is a sole owner are considered
one and the same.
Immediate family member means a husband or wife of a physician; birth or adoptive parent, child, or sibling;
stepparent, stepchild, stepbrother, or stepsister; father-in-law, mother-in-law, son-in-law, daughter-in-law,
brother-in-law, or sister-in-law; grandparent or grandchild; and spouse of a grandparent or grandchild.
Physician-owned hospital means any Medicare participating hospital (as defined in 42 C.F.R. § 489.24) in
which a physician, or an immediate family member of a physician, has an ownership or investment interest in
the hospital. The ownership or investment interest may be through equity, debt, or other means, and includes
an interest in an entity that holds an ownership or investment interest in the hospital. This definition does
not include a hospital with physician ownership or investment interests that satisfy the requirements at 42
C.F.R. § 411.356(a) or (b).
Physician Owner/Investor means a physician (or an immediate family member of such physician) with a direct
or an indirect ownership or investment interest in the hospital.
Important: Pursuant to section 1877(i)(2) of the Act, information collected in this form may be published on
the official CMS internet site.

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INSTRUCTIONS FOR COMPLETING THIS REPORT

SECTION 2 must be completed for every organization that has any percentage of ownership or investment
interest in the physician-owned hospital.
This reporting requirement includes the following types of organizations:
• Organizations that have a physician owner(s), and which have an ownership or investment interest in the
physician-owned hospital.
Example: “Doctors LLC” has an ownership interest in the physician-owned hospital. Doctors LLC is owned by
Dr. Johnson and Dr. Smith. Doctors LLC’s ownership interest must be reported in Section 2. Dr. Johnson and
Dr. Smith’s ownership interests must be reported in Section 3.
• Organizations that have no physician owners, but which have an ownership or investment interest in the
physician-owned hospital.

Example: “Real Estate LLC” is not owned by any physicians, but has an investment interest in the physician-

owned hospital. Real Estate LLC’s investment interest must be reported in Section 2.

SECTION 3 must be completed for every individual who has any percentage of ownership or investment
interest in the physician-owned hospital.

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This reporting requirement includes the following types of individuals:
• All physicians who have a direct or indirect ownership or investment interest in the physician-owned
hospital.
Example: “Care Facilities, Inc.” has a direct ownership interest in the physician-owned hospital. Dr. Johnson
has a direct ownership interest in Care Facilities, Inc., and, as a consequence, an indirect ownership interest
in the physician-owned hospital. Dr. Johnson’s ownership interest must be reported in Section 3. Care
Facilities Inc. must be reported in Section 2 as a direct owner and Section 3 as the organization through
which Dr. Johnson has an indirect ownership interest.
• A physician’s immediate family members who have a direct or indirect ownership or investment interest in a
physician-owned hospital.
Example: Dr. Johnson’s wife, who is not a physician, has a direct ownership interest in the physician-owned
hospital. Mrs. Johnson’s ownership interest must be reported in Section 3.

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• All individuals who are not physicians or immediate family members of a physician, but who have a direct
or indirect ownership or investment interest in the physician-owned hospital.

Example: Nancy Jones, a teacher, has a direct ownership interest in the physician-owned hospital.

Ms. Jones’s ownership interest must be reported in Section 3.

SECTION 5 must be signed by a delegated or authorized official who was previously reported and approved
on the CMS-855A Provider Enrollment Application at the time the physician-owned hospital was enrolled or
when a CMS-855A was submitted to report a change in the delegated or authorized official.

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SECTION 2: OWNERSHIP OR INVESTMENT INTEREST INFORMATION (ORGANIZATIONS)

NOTE: If there is more than one organization, copy and complete this section for each.
A. ORGANIZATION IDENTIFYING INFORMATION
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, Apt. #, etc.)
City/Town

State

ZIP Code + 4

Tax Identification Number (Required)
NPI (if issued)

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Medicare Identification Number(s) (PTAN) (if issued)

B. ORGANIZATION PERCENT OF OWNERSHIP OR INVESTMENT INTEREST

%

Effective (mm/dd/yyyy)

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%

Effective (mm/dd/yyyy)

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Percentage and effective date of direct ownership/investment
interest

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Percentage and effective date of direct ownership/investment
interest

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SECTION 3: OWNERSHIP OR INVESTMENT INTEREST INFORMATION (INDIVIDUALS)
NOTE: If there is more than one individual, copy and complete this section for each.
A. INDIVIDUAL IDENTIFYING INFORMATION
First Name

Middle Initial Last Name

Social Security Number (Required)

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

Date of Birth (mm/dd/yyyy)

Place of Residence (City/Town and State)
Medicare Identification Number (PTAN) (if issued)

NPI (if issued)

Check here if the individual identified above is a physician.
Check here if the individual identified above is an immediate family member of a physician.
B. PERCENT OF OWNERSHIP OR INVESTMENT INTEREST

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%

Percentage and effective date of indirect ownership/investment
interest

%

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Percentage and effective date of direct ownership/investment
interest

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Effective (mm/dd/yyyy)

Effective (mm/dd/yyyy)

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C. INDIRECT OWNERSHIP/INVESTMENT INTEREST INFORMATION
If the individual above has an indirect ownership or investment interest, provide the name and address of the
organization through which the individual has the indirect ownership or investment interest. If the individual
has an indirect ownership or investment interest in the hospital through multiple organizations, then copy
and complete this section for each organization.

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Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)

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

State

ZIP Code + 4

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

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NPI (if issued)

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SECTION 4: CONTACT PERSON INFORMATION
If questions arise concerning the information submitted in this report, the MAC will contact the individual
checked below.
Contact the Authorized Official in Section 5.
Contact person listed below.
First Name

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

ZIP Code + 4

State

Telephone Number

Fax Number (if applicable)

E-mail Address (if applicable)

Relationship or Affiliation to this Provider

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NOTE: The Contact Person will be authorized to discuss only issues concerning this report. The MAC will not
discuss any other Medicare issues for this provider with the above Contact Person.

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SECTION 5: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE
A. CERTIFICATION STATEMENT AND SIGNATURE

This report must be signed by a Delegated or Authorized Official previously reported on a CMS-855A
Enrollment Application.
READ, SIGN AND DATE this certification statement before returning this report. In doing so, you are attesting
to meeting the Medicare requirements stated below.

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Under penalty of perjury, I, the undersigned, certify to the following:
1. I have read the contents of this report, and the information contained herein is true, correct and complete.
2. I understand that any deliberate omission, misrepresentation, or falsification of any information contained
in this report or contained in any communication supplying information to Medicare, or any deliberate
alteration of any text on this reporting form, may be punished by criminal, civil, or administrative penalties
including, but not limited to, revocation of Medicare billing number(s), and/or the imposition of fines, civil
damages, and/or imprisonment.
3. I agree to abide by the Social Security Act and all applicable Medicare laws, regulations and program
instructions that apply to this provider. 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 Stark law which is set forth at 42 U.S.C. § 1395nn or § 1877
of the Social Security Act). The Medicare laws, regulations and program instructions are available through
the MAC.
4. Neither I, nor any physician reported on this form is currently debarred or excluded by the Medicare or
State Health Care program, e.g., Medicaid, or other Federal program, or is otherwise prohibited from
providing services to Medicare or other Federal program beneficiaries.
Delegated or Authorized Official Signature and Date
First Name (Print)
Telephone Number

Middle Initial

Last Name (Print)

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. Stamped, faxed or copied signatures will not be accepted.
Reports not signed and dated will not be processed and will be returned.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE PROVIDER 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) and NPI’s for each disclosing entity, owners, 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 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.

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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 REPORT TO THIS ADDRESS. Mailing to this address will significantly delay processing this report.
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