Form CMS-10495 AM and AGPO Registration

AM and AGPO Registration
Data elements collected to register applicable manufacturers and applicable group purchasing organizations
DE #
Data Element Name
Applicable Manufacturer or Applicable Group Purchasing Organization Identifiers

Description

1

Registering entity legal name

Legal name of either for the applicable manufacturer or applicable group purchasing organization.

2

Doing business as (DBA) name

The DBA name of the applicable manufacturer or applicable group purchasing organization, meaning the trade name, or fictitious business name, under which
the business or operation is conducted and presented to the world and not the legal name of the applicable manufacturer or applicable group purchasing
organization.

3

Consolidated report indicator

Indicator showing whether the applicable manufacturer or applicable group purchasing organization registering intends to be part of a consolidated report.

4

Parent company name

The name of parent company if the applicable manufacturer or applicable group purchasing organization registering is a subsidiary of a parent company.

5

URL of parent company

The uniform resource locator (URL) or web address, which is a specific character string that constitutes a reference to a resource for the applicable manufacturer
or applicable group purchasing organization. If the entity registering is a subsidiary to a parent company, provide the URL of the parent company.

6

Registering entity business type

Applicable manufacturers and applicable group purchasing organizations are required to identify the type of applicable manufacturer or applicable group
purchasing organization.

7

Registering entity type of
ownership

Applicable manufacturers and applicable group purchasing organizations are required to select a corresponding type of ownership from the following list: (1) sole
proprietorship, (2) partnership, (3) corporation, or (4) other. Applicable manufacturers and applicable group purchasing organizations indicated other will be
required to describe their type of ownership.

8

Tax Identifier Number (TIN):
EIN - Employer Identification
Number

The Employer Identification Number (EIN), also known as a federal tax identification number (TIN) used to identify a business entity (an applicable manufacturer
or applicable group purchasing organization).

9

FDA Establishment Identifier
(FEI)

FDA Establishment Identifier (FEI) or the unique identifier designated by FDA to assign, monitor, and track inspections of FDA regulated entities. These
establishments are required to register annually with the FDA. http://www.access.fda.gov/
An establishment identifier (or registration number) is assigned to all establishments or facilities registered with the FDA, including entities which manufacture,
prepare, propagate, compound or process drugs that are commercially distributed in the U.S. or offered for import to the U.S. and that are involved in the
production and distribution of medical devices intended for use in the United States.

10

DUN & Bradstreet (D&B)
D-U-N-S® Number

A unique nine digit identification number for each physical location of a business provided by D&B.

11

Registering entity business
Address

The primary business address (Number and Street (or PO Box), City, State, and 9-digit Zip Code) of the applicable manufacturer or applicable group purchasing
organization. For international addresses, also provide the Province, Country and International Postal Code, if applicable.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

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AM and AGPO Registration
DE #
12

Data Element Name
Registering entity business
telephone number

Description
The business telephone number for the applicable manufacturer or applicable group purchasing organization.

Identifiers for the Authorized Official registering the applicable manufacturer or applicable group purchasing organization
13

CMS User ID

System generated CMS User ID assigned by EIDM and required for registration in Open Payments.

14

Authorized Official Name

The name for an individual (Authorized Official) of the applicable manufacturer or applicable group purchasing organization, who is an officer of the entity and
may submit or attest to data on behalf of the entity and register the entity or approve the Registrant(s).

15

Verify Authorized Official's
relationship with applicable
manufacturer or applicable
group purchasing organization

Provide information to verify the Authorized Official's relationship with the applicable manufacturer or applicable group purchasing organization. This is an
optional field, which will assist in verifying the Authorized Official has authority to register the entity, nominate and approve additional individuals to work on
behalf of the applicable manufacturer or applicable group purchasing organization.

16

Authorized Official Job Title

The job title for an individual (Authorized Official) of the applicable manufacturer or applicable group purchasing organization, who is an officer of the entity and
may submit or attest to data on behalf of the entity and register the entity or approve the Registrant(s).

17

Authorized Official Phone
Number

The phone number for an individual (Authorized Official) of the applicable manufacturer or applicable group purchasing organization, who is an officer of the
entity and may submit or attest to data on behalf of the entity and register the entity or approve the Registrant(s).

18

Authorized Official Email

The email address for an individual (Authorized Official) of the applicable manufacturer or applicable group purchasing organization, who is an officer of the
entity and may submit or attest to data on behalf of the entity and register the entity or approve the Registrant(s).

19

Authorized Official Business
Address

The primary business address (Number and Street (or PO Box), City, State, and 9-digit Zip Code) of the individual, who is an officer of the entity and may submit
or attest to data on behalf of the entity and register the entity or approve the Registrant(s). For international addresses, also provide the Province, Country and
International Postal Code, if applicable.

20

Points of contact

21

Entity Authorized Representative Legal name (first, middle, last, suffix) of an individual authorized by the entity Authorized Official to access, review, and submit data on behalf of the entity.
Name
Applicable manufacturers and applicable group purchasing organizations have the opportunity to identify more than one authorized representative. Each
authorized representative is designated as an officer, submitter, or attester.
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, and submit
Job Title
data on behalf of the entity.

Individuals registering an applicable manufacturer or applicable group purchasing organization are required to provide identifiers for two points of contact,
including the name, job title, email address, and phone number for each point of contact.
Identifiers for applicable manufacturer or applicable group purchasing Authorized Representative

22

23

Entity Authorized Representative The primary business email address of an individual authorized by the entity Authorized Official to access, review, and submit data on behalf of the entity.
Email Address

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

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AM and AGPO Registration
DE #
24

Data Element Name
Description
Entity Authorized Representative The primary business address of an individual authorized by the entity Authorized Official to access, review, and submit data on behalf of the entity.
Business Address

25

Entity Authorized Representative The primary business phone number of an individual authorized by the entity Authorized Official to access, review, and submit data on behalf of the entity.
Phone Number

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

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