| CMS-10220 - RESECTIONING & REVISION MAPPING GUIDE |
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| Current Section Location |
Current Section Header (OMB form approved 02/14) |
New Section Location |
New Section Header |
Revisions |
| Title |
SECURITY CONSENT AND SURROGATE AUTHORIZATION FORM |
Title |
SECURITY CONSENT AND SURROGATE AUTHORIZATION FORM |
Header, right side: add Expiration Date |
| 1 |
Security Consent and Surrogate Authorization Form Purpose and Definitions |
n/a |
Instructions for Completing the Security Consent and Surrogate Authorization Form |
Add Note at the end of Instructions in bold: NOTE: LACK OF PROPER DOCUMENTATION (e.g., Government Issued identification for individuals and Internal Revenue Service (IRS) CP-575 (or equivalent) WILL RESULT IN A REJECTION OF THIS REQUEST. |
| 2 |
Confirmation of Understanding and Penalties for Falsifying Information for Individual or Organizational Provider |
n/a |
Examples |
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| 3A |
Individual Provider |
1 |
Security Consent and Surrogate Authorization Form Purpose and Definitions |
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| 3B |
Organizational Provider |
2 |
Confirmation of Understanding and Penalties for Falsifying Information for Individual or Organizational Provider |
Add Note at the end of Section 2 in bold: NOTE: LACK OF PROPER DOCUMENTATION (e.g., Government Issued identification for individuals and Internal Revenue Service (IRS) CP-575 (or equivalent) WILL RESULT IN A REJECTION OF THIS REQUEST. |
| 4 |
CMS Computer Systems |
3A |
Individual Provider |
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| 5A |
Surrogate Organization |
3B |
Organizational Provider |
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| 5B |
Surrogate Individual |
4 |
CMS Computer Systems |
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| n/a |
Instructions for Completing the Security Consent and Surrogate Authorization Form |
5A |
Surrogate Organization |
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| n/a |
Examples |
5B |
Surrogate Individual |
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6 |
Required Documentation and Submission Instructions |
Added section 6 per NPPES |