Form CMS-10495 Registration

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Registration – Physicians & Teaching Hospitals,
Applicable Manufacturers and Group
Purchasing Organizations
The screen shots below illustrate the registration for Physicians, Teaching Hospitals, Applicable
Manufacturers, and Group Purchasing Organizations on “Open Payments” Web Portal:

[Type here]
OMB Control No.:
0938-1237 Expiration Date:
XX/XXXX

Physician Registration

Data elements collected to register physician covered recipients
DE #
Data Element Name
Description
Physician Identifiers
CMS User ID
1
System generated CMS User ID assigned by EIDM and required for registration in Open Payments.
2

Registering Physician Name

The legal name (first, middle, last, suffix) of the physician. Provide the legal name as listed in the National Plan & Provider Enumeration System (NPPES).

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

1

OMB Control No:
0938-1237 Expiration Date:
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[Type here]
3

Registering Physician NPI (National
Provider Identifier)

4

Registering Physician License Number A valid, official state license number and the state of the physician (covered recipient); provide the "License State and License Number" pairs, if a physician is licensed in
and License State
multiple states.

5

Registering Physician DEA Number

A valid U.S. Drug Enforcement Administration (DEA) number assigned to a health care provider for tracking of prescribed controlled substances.

6

Registering Physician Primary Type

Primary type of medicine practiced by the physician (covered recipient). For the purposes of Open Payments, covered recipient physicians may be any of the following:
Medical Doctor (MD), Doctor of Osteopathy (DO), Doctor of Dentistry (DDS), Doctor of Podiatric Medicine (DPM), Doctor of Optometry (OD), and Chiropractor (DCP).

7

Registering Physician Specialty Code

The physician specialty code of the physician (covered recipient) as listed in the health care provider taxonomy codes list.

8

Registering Physician Email

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

Physician Practice Identifiers
9
Registering Physician Practice Name

Individual NPI for a single physician (and not the NPI of a group of physicians). The National Plan and Provider Enumeration System (NPPES) collects identifying
information on health care providers and assigns each a unique National Provider Identifier (NPI).

The legal name of the practice or group practice (a single legal entity with two or more physicians legally organized as a partnership, professional corporation,
foundation, not-for-profit-corporation, faculty practice plan, or similar association). Physicians have the option to enter additional practice names.

10

Physician Practice Business Address

The primary business (or practice location) address (Number and Street (or PO Box), City, State, and 9-digit Zip Code) of the physician (covered recipient), who has
received payments or transfers of value. For international addresses, also provide the Province, Country and International Postal Code, if applicable. Physicians have the
option to enter addition practice business addresses.

11

Registering Physician Practice Phone
Number

The primary business phone number for the physician (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.

Physician Authorized Representative Identifiers
12
Registering Physician Authorized
Legal name (first, middle, last, suffix) of an individual authorized by the physician (covered recipient) to access/review data and initiate a dispute on behalf of the
Representative Name
physician.
13

Registering Physician Authorized
Representative Job Title

The official title of the job or position held by the individual or employee of the physician practice authorized by the physician to access and review the physician's data or
initiate a dispute in Open Payments.

14

Registering Physician Authorized
Representative Email Address

The primary business email address for the individual or employee of the physician practice authorized by the physician to access/review data and initiate a dispute on
behalf of the physician in Open Payments.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

2

[Type here]
Physician Registration

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

15

Registering Physician Authorized
Representative Phone Number

The primary business phone number for the individual or employee of the physician practice authorized by the physician to access/review data and initiate a dispute on
behalf of the physician.

16

Registering Physician Authorized
Representative Business Address

The primary business address for the individual or employee of the physician practice authorized by the physician to access/review data and initiate a dispute on behalf
of the physician.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW

3

Teaching Hospital Registration

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

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

OMB Control No:
0938-1237 Expiration Date:
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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

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

OMB Control No:
0938-1237 Expiration Date:
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Section 1: Physician Registration
Select “Create My Profile” from the landing page (Yellow Arrow)

Teaching Hospital Registration
OMB Control No:
0938-1237 Expiration Date:
XX/XXXX
Read the messages below and then click “Start Profile” in the second screen shot (bottom of screen):

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Choose “Physician” and then hit the “Continue” button

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Enter your personal information and then click “Continue”

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Enter your Physician details and then hit “Continue”

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

Enter the Authorized Representative and then hit “Submit”. You will get an email once your have been
vetted by the system and authorized to access the site.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration
OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Section 2: Teaching Hospitals

Select “Create My Profile” from the landing page (Yellow Arrow)

Read the messages below and then click “Start Profile” in the second screen shot (bottom of screen):

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

Choose “Teaching Hospital” and then hit the “Continue” button

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

Enter your hospital information and then hit “Search”. Once your hospital is populated hit the
“Continue” button

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Enter your role and select “Continue”

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Fill out your “Personal Information” and then hit “Continue”

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

Once completed you will get an automatically generated email confirming that you can now log on to
the Open Payments website.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Section 3: Applicable Manufacturers and Group Purchasing Organizations

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Go to the Open Payments landing page and choose “Manage Entities” (Yellow Arrow below)

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration

Click on the “Register New Entity” button (Yellow Arrow below)

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

Choose “Applicable Manufacturer or Applicable Group Purchasing Organization and hit “Continue”

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Teaching Hospital Registration
OMB Control No:
0938-1237 Expiration Date:
XX/XXXX
Enter your TIN/EIN and hit find, then once it populates choose “Continue”

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

Enter your information below, and then hit continue

Teaching Hospital Registration
OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date: Teaching Hospital Registration
XX/XXXX
Enter your role with the entity and then hit “Continue”, this will prompt you to review your info, and
then hit “Submit”

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED

OMB Control No:
0938-1237 Expiration Date:
XX/XXXX

Teaching Hospital Registration

Now you will receive a confirmation email and you will now be able to access the Open Payments
system

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED