Form CMS-10495 Teaching Hospitals Registration

Teaching Hospital Registration
Data elements collected to register teaching hospitals
DE #
Data Element Name
Description
Teaching Hospital Identifiers
1
Registering teaching hospital
Legal business name of the teaching hospital (covered recipient), who has received payments or transfers of value. Hospital's registering as a Teaching Hospital
legal name
in Open Payments must be listed on the current Open Payments Teaching Hospital List.
2

Registering teaching hospital
business address

The primary business address (Number and Street (or PO Box), City, State, and 9-digit Zip Code) of the teaching hospital (covered recipient), who has received
payments or transfers of value.

3

Registering teaching hospital
business phone number

The primary business phone number for the teaching hospital (covered recipient),who has received a payment or transfer of value. Provide the preferred phone
number for communications from Open Payments about the program and information reported by applicable manufacturers and applicable group purchasing
organizations about the covered recipient.

4

Teaching Hospital NPI

The group National Provider Identifier (NPI) for the group practice employer, who is a healthcare provider (covered entity under HIPAA) employing physicians,
who furnish services at the group office(s). The National Plan and Provider Enumeration System (NPPES) collects identifying information on health care providers
and assigns each a unique National Provider Identifier (NPI).

5

Physician Tax Identifier Number
(TIN):
EIN - Employee Identification
Number

The Employer Identification Number (EIN) for the teaching hospital (covered recipient)

Identifiers for the Authorized Official registering the teaching hospital
6
CMS User ID
System generated CMS User ID assigned by EIDM and required for registration in Open Payments.
7

Authorized Official Name

The name for an individual (Authorized Official) of the teaching hospital, who is an authorized signatory of the teaching hospital and may register the teaching
hospital, review and dispute data on behalf of the teaching hospital, and approve a Registrant as an Authorized Representative.

8

Provide information to verify the Authorized Official's relationship with the teaching hospital. This is an optional field, which will assist in verifying the Authorized
Official has authority to register the teaching hospital.

9

Verify Authorized Official's
relationship with teaching
hospital
Authorized Official Job Title

10

Authorized Official Email

The email for an individual (Authorized Official) of the teaching hospital, who is an authorized signatory of the teaching hospital and may register the teaching
hospital, review and dispute data on behalf of the teaching hospital, and approve a Registrant as an Authorized Representative.

11

Authorized Official Phone
Number

The phone number for an individual (Authorized Official) of the teaching hospital, who is an authorized signatory of the teaching hospital and may register the
teaching hospital, review and dispute data on behalf of the teaching hospital, and approve a Registrant as an Authorized Representative.

12

Authorized Official Business
Address

The primary business address (Number and Street (or PO Box), City, State, and 9-digit Zip Code) for an individual (Authorized Official) of the teaching hospital,
who is an authorized signatory of the teaching hospital and may register the teaching hospital, review and dispute data on behalf of the teaching hospital, and
approve a Registrant as an Authorized Representative. For international addresses, also provide the Province, Country and International Postal Code, if
applicable.

The job title for an individual (Authorized Official) of the teaching hospital, who is an authorized signatory of the teaching hospital and may register the teaching
hospital, review and dispute data on behalf of the teaching hospital, and approve a Registrant as an Authorized Representative.

Identifiers for the teaching hospital Authorized Representative

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

1

Teaching Hospital Registration
DE #
13

Data Element Name
Description
Entity Authorized Representative Legal name (first, middle, last, suffix) of an individual authorized by the entity Authorized Official to access/review data and initiate a dispute on behalf of the
teaching hospital.
Name

14

Entity Authorized Representative The official title of the job or position held by the individual or employee of the entity authorized by the entity Authorized Official to access/review data and
Job Title
initiate a dispute on behalf of the teaching hospital.

15

Entity Authorized Representative The primary business email address of an individual authorized by the entity Authorized Official to access/review data and initiate a dispute on behalf of the
Email Address
teaching hospital.

16

Entity Authorized Representative The primary business phone number of an individual authorized by the entity Authorized Official to access/review data and initiate a dispute on behalf of the
Phone Number
teaching hospital.

17

Entity Authorized Representative The primary business address of an individual authorized by the entity Authorized Official to access/review data and initiate a dispute on behalf of the teaching
Business Address
hospital.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

2