Information Collection Instruments

INFORMATION COLLECTION INSTRUMENTS
CMS-10357: Letter Requesting Waiver of Medicare/Medicaid Enrollment Application Fee;
Submission of Fingerprints; Submission of Medicaid Identifying Information; Medicaid Site
Visit and Rescreening
I.

Medicare Enrollment Application Fee Waiver Request
Certain providers and suppliers enrolling in Medicare are required to submit a fee with their
application. If the applicant believes it has a hardship that justifies a waiver of the fee, it may
submit a letter describing said hardship. No standard form letter has been or will be created
and no specific format will be required. However, the provider’s letter, which must
accompany its enrollment application, must:



II.

Identify the provider
Explain why a waiver of the application fee should be granted

Fingerprints
Certain providers and suppliers enrolling in Medicare and Medicaid will be required to
submit standard FD-258 fingerprint cards for their owners, authorized officials, delegated
officials, and managing employees.

III.

Collection of SSNs and DOBs for Medicaid and CHIP providers

The State Medicaid agency must require that all persons with an ownership or control interest
in a Medicaid provider submit their SSNs and DOBs. For most, if not all, State Medicaid
agencies, these two data elements are collected via the respective Medicaid provider
enrollment form for that particular State.
IV.

IV. Site Visits for Medicaid-only or CHIP-only providers

A State Medicaid agency must conduct on-site visits for providers it determines to be
"moderate" or "high" categorical risk. No standard, nationwide form has been or will be
created to record the visit results. Each State records the results via its own chosen
mechanism.
V.

Rescreening of Medicaid Providers Every 5 Years:
A State Medicaid agency must screen all providers at least every 5 years. This is consistent
with the Medicare requirement in current 42 CFR § 424.515 that providers and suppliers
revalidate their enrollment information at least every 5 years. No standard, nationwide form
to rescreen these providers has been or will be created. Again, each State undertakes its
rescreening activities via its own chosen mechanism.