CMS-855A Medicare Enrollment Application - Institutional Provider

Medicare Enrollment Application for Institutional Providers (CMS-855A)

CMS-855A-(Medicare Enrollment Application - Institutional Providers )

OMB: 0938-0685

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MEDICARE ENROLLMENT APPLICATION
INSTITUTIONAL PROVIDERS

CMS-855A
SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION.
SEE PAGE 5 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION.
SEE SECTION 17 TO FIND A LIST OF THE SUPPORTING DOCUMENTATION THAT MUST
BE SUBMITTED WITH THIS APPLICATION.

Form Approved
OMB No. 0938-0685
Expires: XX/XX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

WHO SHOULD SUBMIT THIS APPLICATION

Institutional providers must complete this application to enroll in the Medicare program and receive a
Medicare billing number.

Institutional providers can apply for enrollment in the Medicare program or make a change in their enrollment
information using either:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• The paper CMS-855A enrollment application. Be sure you are using the most current version of the
CMS-855A enrollment application.

For additional information regarding the Medicare enrollment process, including Internet-based PECOS, and to
get the current version of the CMS-855A, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.
NOTE: Applicants using this application require a Type 2 NPI. See below for more information.
The following health care organizations must complete
• Community Mental Health Center
• Comprehensive Outpatient Rehabilitation Facility
• Critical Access Hospital
• End-Stage Renal Disease Facility
• Federally Qualified Health Center
• Histocompatibility Laboratory
• Home Health Agency
• Hospice
• Hospital

this application to initiate the enrollment process:
• Indian Health Services Facility
• Opioid Treatment Program
• Organ Procurement Organization
• Outpatient Physical Therapy/Occupational Therapy/
Speech Pathology Services
• Religious Non-Medical Health Care Institution
• Rural Emergency Hospital
• Rural Health Clinic
• Skilled Nursing Facility

NOTE: Opioid Treatment Programs may complete the CMS-855A or CMS-855B enrollment application.

NOTE: Per Section 125 of the Consolidated Appropriations Act of 2021 (CAA) an action plan is required to be
submitted with the enrollment application.
If your provider type is not listed above, contact your designated Medicare Administrative Contractor (MAC)
before you submit this application.

Complete and submit this application if you are a health care organization that plans to bill Medicare and
you are:
• An institutional organization that will bill for Medicare Part A services (e.g., hospitals, Community Mental
Health Centers, Skilled Nursing Facilities).
• Enrolling in the Medicare program for the first time with this MAC under this tax identification number.
• Currently enrolled in Medicare but have a new Tax Identification Number. If you are reporting a change to
your current Medicare enrollment to your tax identification number, you must complete a new application.
• Currently enrolled in Medicare and need to enroll in another MAC’s jurisdiction (e.g., you have opened a
practice location in a geographic territory serviced by another MAC).
• Revalidating your Medicare enrollment. CMS may require you to submit or update your enrollment
information. The MAC will notify you when it is time for you to revalidate your enrollment information. Do
not submit a revalidation application until you have been contacted by the MAC.
• Previously enrolled in Medicare and you need to reactivate your Medicare billing number to resume
billing. Prior to being reactivated, you must meet all current requirements for your supplier type before
reactivation may occur.
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have
added or changed a practice location). Changes must be reported in accordance with the timeframes
established in 42 C.F.R. section 424.516.

NOTE: Ownership changes that do not qualify as CHOWs, acquisitions/mergers, or consolidations should
be reported. For instance, assume that a business entity’s stock is owned by A, B, and C. A sells his stock to
D. While this is an ownership change, it is generally not a formal CHOW under 42 C.F.R. 489.18. Thus, the
ownership change from A to D should be reported as a change of information, not a CHOW. If you have
any questions on whether an ownership change should be reported as a CHOW or a change of information,
contact your MAC or CMS location.

CMS-855A (XX/XX)

• Reporting a Change of Ownership (CHOW), Acquisition/Merger or Consolidation.
• A CHOW typically occurs when a Medicare provider has been purchased (or leased) by another
organization. The CHOW results in the transfer of the old owner’s Medicare Identification Number and
provider agreement (including any outstanding Medicare debt of the old owner) to the new owner. The
regulatory citation for CHOWs can be found at 42 C.F.R. section 489.18. If the purchaser (or lessee) elects
not to accept a transfer of the provider agreement, the old agreement should be terminated and the
purchaser or lessee is considered a new applicant and must initially enroll in Medicare.
• An acquisition/merger occurs when a currently enrolled Medicare provider is purchasing or has been
purchased by another enrolled provider. Only the purchaser’s Medicare Identification Number and
Tax Identification Number remain. Acquisitions/mergers are different from CHOWs. In the case of an
acquisition/merger, the seller/former owner’s Medicare Identification Number dissolves. In a CHOW, the
seller/former owner’s provider number typically remains intact and is transferred to the new owner.
• A consolidation occurs when two or more enrolled Medicare providers consolidate to form a new
business entity. Consolidations are different from acquisitions/mergers. In an acquisition/merger, two
entities combine but the Medicare Identification Number and Tax Identification Number (TIN) of the
purchasing entity remain intact. In a consolidation, the TINs and Medicare Identification Numbers of the
consolidating entities dissolve and a new TIN and Medicare Identification Number are assigned to the
new, consolidated entity.
Because of the various situations in which a CHOW, acquisition/merger, or consolidation can occur, it
is recommended that the provider contact its MAC if it is unsure as to whether such a transaction has
occurred. The provider should also review the applicable federal regulation at 42 C.F.R. § 489.18 for
additional guidance. Note that the transactions described above as CHOWs, acquisition/mergers, and
consolidations are each considered a type of potential change of ownership under 42 C.F.R. § 489.18 (e.g.,
a consolidation can constitute a 42 C.F.R. § 489.18 CHOW). They are separated into three categories on the
application strictly to help the provider understand the precise data that must be reported.
• Voluntarily terminating your Medicare billing privileges. A provider should voluntarily terminate its
Medicare enrollment when it:
• Will no longer be rendering services to Medicare patients, or
• Is planning to cease (or has ceased) operations.
NOTE: Submit separate CMS-855A enrollment applications if the types of providers for which this application
is being submitted are separately recognized provider types with different rules regarding Medicare
participation. For example, if a provider functions as both a hospital and an end-stage renal disease (ESRD)
facility, the provider must complete two separate enrollment applications (CMS-855A)—one for the hospital
and one for the ESRD facility. If a hospital performs multiple types of services, only one enrollment application
(CMS-855A) is required. To illustrate, a hospital that has a swing-bed unit need only submit one enrollment
application (CMS-855A). This is because the provider is operating as a single provider type—a hospital—that
happens to have a distinct part furnishing different/additional services.

CMS-855I (XX/XX)

BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATION

The Provider Transaction Access Number (PTAN), often referred to as a Medicare Provider Number, Medicare
Billing Number, CMS Certification Number (CCN), or Medicare “legacy” number, is a generic term for any
number other than the National Provider Identifier (NPI) that is used by a provider to bill the Medicare
program.
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers
and suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). Medicare
healthcare providers, except organ procurement organizations, must obtain an NPI prior to enrolling
in Medicare or before submitting a change to your existing Medicare enrollment information.
Applying for an NPI is a process separate from Medicare enrollment. As an organizational health care
provider, it is your responsibility to determine if you have “subparts.” A subpart is a component of
an organization that furnishes healthcare and is not itself a legal entity. If you do have subparts, you
must determine if they should obtain their own unique NPIs. Before you complete this enrollment
application, you need to make those determinations and obtain NPI(s) accordingly. For more
information about subparts, visit CMS.gov/Regulations-and-Guidance/Administrative-Simplification/
NationalProvIdentStand/implementation to view the “Medicare Expectations Subparts Paper.” To obtain
an NPI, you may apply online at nppes.cms.hhs.gov. For more information about NPI enumeration, visit
CMS.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/apply.

NOTE: The Legal Business Name (LBN) and Tax Identification Number (TIN) that you furnish in section 2B1 must
be the same LBN and TIN you used to obtain your NPI. Once this information is entered into PECOS from this
application, your LBN, TIN and NPI must match exactly in both the Medicare Provider Enrollment Chain and
Ownership System (PECOS) and the National Plan and Provider Enumeration System (NPPES).
Organizational Health Care Providers (Entity Type 2): Organizational health care providers are eligible for
an Entity Type 2 NPI (Organizations). Organizational health care providers may have a single employee or
thousands of employees. Examples of organizational providers include hospitals, home health agencies,
groups/clinics, nursing homes, ambulance companies, health care provider corporations formed by groups/
individuals, and single member LLCs with an EIN, but do not include individual health care providers.

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION

All information on this form is required with the exception of those fields specifically marked as “optional.”
Any field marked as optional is not required to be completed nor does it need to be updated or reported as
a “change of information” as required in 42 C.F.R. section 424.516. However, it is highly recommended that if
reported, these fields be kept up-to-date.
• This form must be typed. It may not be handwritten.
• When necessary to report additional information, copy and complete the applicable section as needed.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your records.

TIPS TO AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should:
• Complete all required sections, as shown in section 1.
• Ensure that the Legal Business Name shown in section 2B1 matches the name on the tax documents.
• Ensure that the correspondence address shown in section 2C is the provider’s address.
• Enter your NPI in the applicable section(s).
• Include the Electronic Funds Transfer (EFT) Authorization Agreement (when applicable) with your
enrollment application with a voided check or bank letter.
• Sign and date section 15.
• Ensure all supporting documents are sent to your designated MAC.
• Pay the required application fee (via pecos.cms.hhs.gov/pecos/feePaymentWelcome.do) upon initial
enrollment, the addition of a new practice location, and revalidation PRIOR to completing and submitting
this application to your MAC.

CMS-855A (XX/XX)

OBTAINING MEDICARE APPROVAL
The usual process for becoming a certified Medicare provider is as follows:
1. The applicant completes and submits a CMS-855A enrollment application and all supporting
documentation to its MAC.
2. The MAC reviews the application and makes a recommendation for approval or denial to the State survey
agency, with a copy to CMS.
3. The State agency or approved accreditation organization conducts a survey. Based on the survey results,
the State agency makes a recommendation for approval or denial (a certification of compliance or
noncompliance) to CMS. Certain provider types may elect voluntary accreditation by a CMS-recognized
accrediting organization in lieu of a State survey.
4. The MAC conducts a second contractor review, as needed, to verify that a provider continues to meet the
enrollment requirements prior to granting Medicare billing privileges.
5. CMS makes the final decision regarding program eligibility. If approved, the provider must typically sign a
provider agreement.

ADDITIONAL INFORMATION
• You may visit our website to learn more about the enrollment process via the Internet-Based PECOS at:
CMS.gov/Medicare/Provider-Enrollment-and-Certification/Become-a-Medicare-Provider-or-Supplier. Also, all
of the CMS-855 applications are located on the CMS webpage: CMS.gov/Medicare/CMS-Forms/CMS-Forms/
CMS-Forms-List. Simply enter “855” in the “Filter On:” box on this page and only the application forms will
be displayed to choose from.
• The MAC may request, at any time during the enrollment process, additional documentation to support
or validate information reported on the application. You are responsible for providing this documentation
within 30 days of the request per 42 C.F.R. section 424.525(a)(1).
• The information you provide on this application will not be shared. It is protected under 5 U.S.C. section
552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the
Privacy Act Statement.

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ACRONYMS COMMONLY USED IN THIS APPLICATION

C.F.R: Code of Federal Regulations
EFT: Electronic Funds Transfer
EIN: Employer Identification Number
IHS: Indian Health Service
IRS: Internal Revenue Service
LBN: Legal Business Name
LLC: Limited Liability Company
MAC: Medicare Administrative Contractor
NPI: National Provider Identifier
NPPES: National Plan and Provider Enumeration System
OTP: Opioid Treatment Program
PTAN: Provider Transaction Access Number also referred to as the Medicare Identification Number
SSN: Social Security Number
TIN: Tax Identification Number

CMS-855A (XX/XX)

DEFINITIONS

For the purposes of this CMS-855A application, the following definitions apply:
1. Add: You are adding additional enrollment information to your existing information (e.g. practice
locations).
2. Change: You are replacing existing information with new information (e.g. billing agency, managing
employee) or updating existing information (e.g. change in suite #, telephone #).
3. Remove: You are removing existing enrollment information.

WHERE TO MAIL YOUR APPLICATION

Send this completed application with original signatures and all required documentation to your designated
MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the
mailing address for your designated MAC, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.

CMS-855A (XX/XX)

SECTION 1: BASIC INFORMATION
ALL APPLICANTS MUST COMPLETE THIS SECTION
A. REASON FOR SUBMITTING THIS APPLICATION
Check one box and complete the required sections.
You are a new enrollee in Medicare

Complete all applicable sections except 2G, 2H, and 2I

You are enrolling with another Medicare
Administrative Contractor (MAC)

Complete all applicable sections except 2G, 2H, and 2I

You are reactivating your Medicare enrollment

Complete all applicable sections except 2G, 2H, and 2I

There has been a Change of Ownership (CHOW) of
the Medicare-enrolled provider
You are the:
Seller/Former Owner
Buyer/New Owner

Seller/Former Owner: 1A, 2B1, 2G, 13, and either 15B
(if you are the authorized official) or 15C (if you are
the delegated official)

You are solely enrolling in Medicare to participate
in Medicaid or another health care program and
will not be billing Medicare

Complete all applicable sections except 2G, 2H, and 2I

You are revalidating your Medicare enrollment

Complete all applicable sections except 2G, 2H, and 2I

You are changing your Medicare information

Go to Section 1B

Buyer/New Owner: Complete all sections except 2H
and 2I

Your organization has taken part in an Acquisition
or Merger
You are the:
Seller/Former Owner
Buyer/New Owner
Medicare Identification Number of the Seller/
Former Owner (if issued):

Seller/Former Owner: 1A, 2B1, 2H, 13, either 15B
or 15C, and 6 for the signer if that authorized or
delegated official has not been established for this
provider.

Your organization has Consolidated with another
organization
You are the:
Former organization
New organization
Medicare Identification Number of the Seller/
Former Owner (if issued):

Former Organizations: 1A, 2B1, 2I, 13, and either 15B
(if you are the authorized official) or 15C (if you are
the delegated official)

______________________

You are voluntarily terminating your Medicare
enrollment
Effective date of termination (mm/dd/yyyy):

Buyer/New Owner: 1A, 2H, 4, 13, either 15B (if
you are the authorized official) or 15C (if you are
the delegated official), and 6 for the signer if that
authorized or delegated official has not been
established for this provider.

New Organization: Complete all sections except 2G
and 2H

Complete sections: 1, 2B1, 13, either 15B or 15C,
and 6 for the signer if that authorized or delegated
official has not been established for this provider.

______________________

Medicare Identification Number:
______________________

CMS-855A (XX/XX)

SECTION 1: BASIC INFORMATION (Continued)
B. WHAT INFORMATION IS CHANGING?

Check all that apply and complete the required sections.

Please note: When reporting ANY information, sections 1, 2B1, 3, and 15 MUST always be completed in
addition to the information that is changing within the required section.
Changing Information
Business Identifying Information

Final Adverse Legal Actions

Provider Specific Information

Address Information
Correspondence Mailing Address
Medicare Beneficiary Medical Records Storage
Address
Practice Location Address
Remittance Notices/Special Payment Mailing
Address
Base of Operations Address for Mobile or
Portable Suppliers (location of Business Office
or Dispatcher/ Scheduler)
Ownership Interest and/or Managing Control
Information (Organizations)

Ownership Interest and/or Managing Control
Information (Individuals)

Chain Home Office Information

CMS-855A (XX/XX)

Required Sections

1, 2 (complete only those sections that are changing),
3, 13, and either 15B (if you are the authorized
official) or 15C (if you are the delegated official),
and Section 6 for the signer if that authorized or
delegated official has not been established for this
provider.

1, 2B1, 3, 13, and either 15B (if you are the
authorized official) or 15C (if you are the delegated
official), and Section 6 for the signer if that
authorized or delegated official has not been
established for this provider.
1, 2A1–2A2, 2B1–2B2, 2C–2F (as applicable), 3, 10
(as applicable), 13 (optional), either 15B (if you
are the authorized official) or 15C (if you are the
delegated official), and Section 6 for the signer if
that authorized or delegated official has not been
established for this provider, and 17.

1, 2B1, 3, 4 (complete only those sections that
are changing), 13, and either 15B (if you are
the authorized official) or 15C (if you are the
delegated official), and Section 6 for the signer if
that authorized or delegated official has not been
established for this provider.

1, 2B1, 3, 5, 13, and either 15B (if you are the
authorized official) or 15C (if you are the delegated
official), and Section 6 for the signer if that
authorized or delegated official has not been
established for this provider.
1, 2B1, 3, 6, 13, and either 15B (if you are the
authorized official) or 15C (if you are the delegated
official), and Section 6 for the signer if that
authorized or delegated official has not been
established for this provider.

SECTION 1: BASIC INFORMATION (Continued)
Billing Agency Information

1, 2B1, 3, 8 (complete only those sections that
are changing), 13, and either 15B (if you are the
authorized official) or 15C (if you are the delegated
official), and Section 6 for the signer if that
authorized or delegated official has not

Opioid treatment program personnel

1, 2B1, 3, 10, 13, and either 15B (if you are the
authorized official) or 15C (if you are the delegated
official), and Section 6 for the signer if that
authorized or delegated official has not been
established for this provider.

Special Requirements for Home Health Agencies

1, 2B1, 3, 12, 13, and either 15B (if you are the
authorized official) or 15C (if you are the delegated
official), and Section 6 for the signer if that
authorized or delegated official has not been
established for this provider.

Authorized Official(s)

1, 2B1, 3, 6, 13, and 15B.

Delegated Official(s) (Optional)

1, 2B1, 3, 6, 13, and 15C.

Special Enrollment Notes

• If you are adding a psychiatric or rehabilitation unit to a hospital, check the appropriate subcategory under
the “Hospital” heading. (A separate enrollment for the psychiatric/rehabilitation unit is not required). The
unit should be listed as a practice location in Section 4.
• If you are adding a home health agency (HHA) branch, list it as a practice location in Section 4. A separate
enrollment application is not necessary.
• If you are changing hospital types (e.g., general hospital to a psychiatric hospital), indicate this in Section 2.
A new/separate enrollment is not necessary.
• If the hospital will focus on certain specialized services, the applicant should analyze whether the facility
will be a general hospital or will fall under the category of a specialty hospital. A specialty hospital is
defined as a facility that is primarily engaged in cardiac, orthopedic, or surgical care. Based upon Diagnosis
Related Group/Major Diagnosis Category (DRG/MDC) and type (medical/surgical), the applicant should
project all inpatient discharges expected in the first year of the hospital’s operation. Those applicants that
project that 45% or more of the hospital’s inpatient cases will fall in either cardiac (MDC-5), orthopedic
(MDC-8), or surgical care should check the Hospital—Specialty Hospital block in Section 2A2.
• Physician-owned hospital means any participating hospital (as defined in 42 C.F.R. section 489.24) in which
a physician, or an immediate family member of a physician has an ownership or investment interest in the
hospital. The ownership or investment interest may be through equity, debt, or other means, and includes
an interest in an entity that holds an ownership or investment interest in the hospital. This definition does
not include a hospital with physician ownership or investment interests that satisfy the requirements at
42 C.F.R. section 411.356(a) or (b).

CMS-855A (XX/XX)

SECTION 2: IDENTIFYING INFORMATION
A. TYPE OF PROVIDER

The provider must meet all Federal and State requirements for the type of provider checked. Check only one
provider type. If the provider functions as two or more provider types, a separate enrollment application
(CMS-855A) must be submitted for each type.
1. Type of Provider (other than Hospitals— See 2A2). Check only one:
Community Mental Health Center
Comprehensive Outpatient Rehabilitation Facility
Critical Access Hospital
End-Stage Renal Disease Facility
Federally Qualified Health Center
Histocompatibility Laboratory
Home Health Agency
Hospice
Indian Health Services Facility

Opioid Treatment Program
Organ Procurement Organization
Outpatient Physical Therapy/Occupational Therapy/
Speech Pathology Services
Religious Non-Medical Health Care Institution
Rural Emergency Hospital
Rural Health Clinic
Skilled Nursing Facility
Other (Specify): _____________________________

2. If this provider is a hospital, check all applicable subgroups and units listed below and complete
Section 2A3.
Hospital—General
Hospital—Acute Care
Hospital—Children’s (excluded from PPS)
Hospital—Long-Term (excluded from PPS)
Hospital—Psychiatric (excluded from PPS)
Hospital—Rehabilitation (excluded from PPS)
Hospital—Short-Term (General and Specialty)

Hospital—Swing-Bed approved Hospital—
Psychiatric Unit
Hospital—Rehabilitation Unit
Hospital—Specialty Hospital (cardiac, orthopedic,
or surgical)
Hospital—Transplant Program (Identify organ
type(s)):
Other (Specify):

3. If “hospital” was checked in Section 2A1 or 2A2, does this hospital have a compliance plan
that states that the hospital checks all managing employees against the exclusion/debarment
lists of both the HHS Office of the Inspector General (OIG) and the General Services
Administration (GSA)? ............................................................................................................................
4. Is the provider a physician-owned hospital (as defined in the Special Enrollment Notes
on page 8)? ..............................................................................................................................................

CMS-855A (XX/XX)

Yes

SECTION 2: IDENTIFYING INFORMATION (Continued)
B. IDENTIFICATION INFORMATION
1. Business Information
Legal Business Name as reported to the Internal Revenue Service (IRS)
Other Name (if applicable)
Tax Identification Number (TIN)

Medicare Identification Number (PTAN) (if issued)

National Provider Identifier (NPI)

What is the provider’s year end cost report date? (mm/dd/yyyy)

Type of Other Name (if applicable)
Check box indicating Type of Other Name:
Former Legal Business Name

Doing Business As Name

Other (Specify):

IRS Business Designation
Identify how your business is registered with the IRS. (NOTE: If your business is a Federal and/or State
government supplier, indicate “Non-Profit” and specify the level below. In addition, government-owned
entities do not need to provide an IRS Form 501(c)(3)).
Proprietary
Non-Profit (Submit IRS Form 501(c)(3))
Disregarded Entity (Submit IRS Form 8832, if applicable)

NOTE: If a checkbox identifying how the business is registered with the IRS is not completed, the supplier will
be defaulted to “Proprietary.”
Identify the business structure: (Check one)
Corporation
Limited Liability Company
Partnership
Sole Proprietor
Other (Specify):

Federal and/or State Government Type:
Federal
State
City
County
City-County
Hospital District
Other (Specify):

Is this provider an Indian Health Service (IHS) Facility? ..........................................................................

CMS-855A (XX/XX)

Yes

SECTION 2: IDENTIFYING INFORMATION (Continued)
2. License/Certification/Registration Information

Complete the appropriate subsection(s) below for your provider type you reported in section 2A1. If no
subsection is associated with your provider type, check the box stating the information is not applicable.
a. Active License Information
License Not Applicable
License Number

Effective Date (mm/dd/yyyy)

State Where Issued

b. Active Certification Information
Complete the appropriate subsection(s) below for your provider type you reported in section 2A1. If no
subsection is associated with your provider type, check the box stating the information is not applicable.
*If you are certified by a national entity, put the word “all” in the “State Where Issued” data field.
Certification Not Applicable

Certification Number

Effective Date (mm/dd/yyyy)

State Where Issued

Certifying Entity (Specialty Board, State, Other)

C. CORRESPONDENCE MAILING ADDRESS

This is the address where correspondence will be sent to the provider listed in section 2B1 by your designated
MAC. This address cannot be a billing agent or agency’s address or a medical management company address.
If you are reporting a change to your Correspondence Mailing Address, check the box below. This will replace
any current Correspondence Mailing Address on file.
Change

Effective Date (mm/dd/yyyy):

Attention (optional)
Correspondence Mailing Address Line 1 (P.O. Box or Street Name and Number)
Correspondence Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number (if applicable)

CMS-855A (XX/XX)

State
Fax Number (if applicable)

ZIP Code + 4
E-mail Address (if applicable)

SECTION 2: IDENTIFYING INFORMATION (Continued)
D. MEDICAL RECORD CORRESPONDENCE ADDRESS

This is the address where the medical record correspondence will be sent to the provider listed in Section 2B1
by your designated MAC. This information would be used for any medical record review requests.
Check here if your Medical Record Correspondence Address should be mailed to your Correspondence
Address in Section 2C (above) and skip this section.

If you are reporting a change to your Medical Record Correspondence Address, check the box below. This will
replace any current Medical Record Correspondence Address on file.
Change

Effective Date (mm/dd/yyyy):

Attention (optional)
Medical Record Correspondence Mailing Address Line 1 (P.O. Box or Street Name and Number)
Medical Record Correspondence Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number (if applicable)

State

ZIP Code + 4

Fax Number (if applicable)

E-mail Address (if applicable)

E. ACCREDITATION
Is this provider accredited? ....................................................................................................................
If yes, complete the following:
Date of Accreditation (mm/dd/yyyy)

Yes

Expiration Date of Accreditation (mm/dd/yyyy)

Name of Accrediting Body
Type of Accreditation or Accreditation Program (e.g., hospital accreditation program, home health accreditation, etc.)

F. COMMENTS

Use this section to clarify any information furnished in this section.

CMS-855A (XX/XX)

SECTION 2: IDENTIFYING INFORMATION (Continued)
G. CHANGE OF OWNERSHIP (CHOW) INFORMATION

Both the seller/former owner and the new owner should complete this section. (As the new owner may
not know all of the seller/former owner’s data, it should furnish this information on an “if known” basis.)
The seller/former owner must complete Sections 1A, 2G, 13, and either 15B or 15C. (Section 6 must also be
completed if the signer has never completed Section 6 before.) The new owner must complete the entire
application.
Legal Business Name of “Seller/Former Owner” as reported to the Internal Revenue Service
“Doing Business As” Name of Seller/Former Owner (if applicable)
Old Owner’s Medicare Identification Number (if issued)

Old Owner’s NPI

Effective Date of Transfer (this can be a future date) (mm/dd/yyyy)

Name of MAC of Seller/Former Owner

Will the new owner be accepting assignment of the current “Provider Agreement?” ....................

Yes

If no, this is an initial enrollment and the new owner should follow the instructions in the “Who Should
Submit This Application” section of this form.

Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.

CMS-855A (XX/XX)

SECTION 2: IDENTIFYING INFORMATION (Continued)
H. ACQUISITIONS/MERGERS
Effective Date of Acquisition (mm/dd/yyyy)

The seller/former owner need only complete Sections 1A, 2H, 13, and either 15B or 15C; the new owner must
complete Sections 1A, 2H, 4, 13, and either 15B or 15C. (Section 6 must also be completed if the signer has
never completed Section 6 before.)

1. Provider Being Acquired

This section is to be completed with information about the currently enrolled provider that is being acquired
and will no longer retain its current Medicare provider number as a result of this acquisition.
Legal Business Name of the “Provider Being Acquired” as reported to the Internal Revenue Service
Current MAC

Provide the name and Medicare Identification Number of all units of the above provider that have separate
Medicare Identification Numbers but have not entered into separate provider agreements, such as swing bed
units of a hospital and HHA branches. Also, furnish the unit’s NPI. Units that already have a separate provider
agreement should not be reported here.
NAME/DEPARTMENT

MEDICARE IDENTIFICATION
NUMBER (IF ISSUED)

NATIONAL PROVIDER IDENTIFIER

2. Acquiring Provider

This section is to be completed with information about the organization acquiring the provider identified in
Section 2H1.
Legal Business Name of the “Acquiring Provider” as Reported to the Internal Revenue Service
Medicare Identification Number (if issued)

National Provider Identifier

Current MAC

Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.

CMS-855A (XX/XX)

SECTION 2: IDENTIFYING INFORMATION (Continued)
I. CONSOLIDATIONS

The newly formed provider completes the entire application. The providers that are being consolidated are
reported below.

1. 1st Consolidating Provider

This section is to be completed with information about the 1st currently enrolled provider that, as a result of
this consolidation, will no longer retain its current Medicare Identification Number.
Legal Business Name of the “Provider Being Acquired” as reported to the Internal Revenue Service
Current MAC
Effective Date of Consolidation

Provide the name and Medicare Identification Number of all units of the above provider that have separate
Medicare Identification Numbers but have not entered into separate provider agreements, such as swing- bed
units of a hospital and HHA branches. Also, furnish the unit’s NPI. Units that already have a separate provider
agreement should not be reported here.
NAME/DEPARTMENT

MEDICARE IDENTIFICATION
NUMBER (IF ISSUED)

NATIONAL PROVIDER IDENTIFIER

2. 2nd Consolidating Provider

This section is to be completed with information about the 2nd currently enrolled provider that, as a result of
this consolidation, will also no longer retain its current Medicare Identification Number.
Legal Business Name of the “Provider Being Acquired” as reported to the Internal Revenue Service
Current MAC

Provide the name and Medicare Identification Number of all units of the above provider that have separate
Medicare Identification Numbers but have not entered into separate provider agreements, such as swing- bed
units of a hospital and HHA branches. Also, furnish the unit’s NPI. Units that already have a separate provider
agreement should not be reported here.
NAME/DEPARTMENT

CMS-855A (XX/XX)

MEDICARE IDENTIFICATION
NUMBER (IF ISSUED)

NATIONAL PROVIDER IDENTIFIER

SECTION 2: IDENTIFYING INFORMATION (Continued)
3. Newly Created Provider Identification Information

Complete this section with identifying information about the newly created provider resulting from this
consolidation.
Legal Business Name of the New Provider as Reported to the Internal Revenue Service
Tax Identification Number

Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.

CMS-855A (XX/XX)

SECTION 3: FINAL ADVERSE LEGAL ACTIONS
This section captures information regarding final adverse legal actions, such as convictions, exclusions, license
revocations and license suspensions. All applicable final adverse legal actions must be reported, regardless of
whether any records were expunged or any appeals are pending.

NOTE: To satisfy the reporting requirement, Section 3 must be filled out in its entirety, and all applicable
attachments must be included.

A. FEDERAL AND STATE CONVICTIONS (“Conviction” as defined in 42 C.F.R. Section 1001.2) WITHIN
THE PRECEDING 10 YEARS

1. Any federal or state felony conviction(s) by the provider, supplier, or any owner or managing employee of
the provider or supplier.
2. Any crime, under Federal or State law, where an individual or entity has entered into participation in a
first offender, deferred adjudication or other program or arrangement where judgment of conviction has
been withheld, or the criminal conduct has been expunged or otherwise removed, or there is a post-trial
motion or appeal pending, or the court has made a finding of guilt or accepted a plea of guilty or nolo
contendere.
3. Any misdemeanor conviction, under federal or state law, related to: (a) the delivery of an item or service
under Medicare or a state health care program, or (b) the abuse or neglect of a patient in connection
with the delivery of a health care item or service.
4. Any misdemeanor conviction, under federal or state law, related to the theft, fraud, embezzlement,
breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care
item or service.
5. Any misdemeanor conviction, under federal or state law, related to the unlawful manufacture,
distribution, prescription, or dispensing of a controlled substance.
6. Any misdemeanor conviction, under federal or state law, related to the interference with or obstruction
of any investigation into any criminal offence described in 42 C.F.R. section 1001.101 or 1001.201.

B. EXCLUSIONS, REVOCATIONS OR SUSPENSIONS
1.
2.
3.
4.

Any current or past revocation or suspension.
Any voluntary surrender of a medical license in lieu of further disciplinary action.
Any current or past revocation or suspension of accreditation.
Any current or past suspension or exclusion imposed by the U.S. Department of Health and Human
Service’s Office of Inspector General (OIG).
5. Any current or past debarment from participation in any Federal Executive Branch procurement or nonprocurement program.
6. Any other current or past federal sanctions (A penalty imposed by a federal governing body (e.g. Civil
Monetary Penalties (CMP)).
7. Any current or past Medicaid or any federal health care program exclusion, revocation, or termination of
any billing number.

C. FINAL ADVERSE LEGAL ACTION

1. Has your organization, under any current or former name or business identity, had a final adverse legal
action listed above imposed against it?
YES – continue below

NO – skip to section 4

2. If yes, report each final adverse legal action, when it occurred, and the federal or state agency or the
court/administrative body that imposed the action.

FINAL ADVERSE LEGAL ACTION

CMS-855A (XX/XX)

DATE

ACTION TAKEN BY

SECTION 4: PRACTICE LOCATION INFORMATION
INSTRUCTIONS

This section captures information about the physical location(s) where you currently provide health care
services.

Complete this section for each of your practice locations where you render services to Medicare beneficiaries.
This includes all locations, where services are rendered, and disclosed on claims forms for reimbursement. If
you have and see patients at more than one practice location or health care facility, copy and complete this
section for each location.
IMPORTANT: The provider should designate its primary practice location in Section 4A. The “primary practice
location” must be associated with the NPI that the provider intends to use to bill for Medicare services.
All reported practice location addresses must be a specific street address as recorded by the United States
Postal Service. Your practice location must be the physical location where you render services to Medicare
beneficiaries. It cannot be a Post Office (P.O.) Box.
Only report those practice locations that are within the jurisdiction of the designated MAC to which you
will be submitting this application. If you have to report practice locations outside the jurisdiction of the
designated MAC to which you are submitting this application, you must submit a separate CMS-855A
enrollment application to the MAC that has jurisdiction for those locations.

If you are enrolling for the first time or adding a new practice location, the date you provide should be the
date you saw your first Medicare patient at this location.

If the provider is adding a practice location in the same state and the location requires a separate provider
agreement, a separate, complete CMS-855A must be submitted for that location. The location is considered a
separate provider for purposes of enrollment, and is not considered a practice location of the main provider. If
a provider agreement is not required, the location can be added as a practice location.
If the provider is adding a practice location in another state and the location requires a separate provider
agreement, a separate, complete CMS-855A must be submitted for that location. (This often happens when a
home health agency wants to perform services in an adjacent state.)
If you have any questions as to whether the practice location requires a separate state survey or provider
agreement, contact your MAC.

• Hospitals must report all practice locations where the hospital provides services. Do not report separately
enrolled provider types such as skilled nursing facilities (SNFs), HHAs, RHCs, etc., even if these entities are
provider-based to the hospital. For example, suppose a hospital owns a SNF and an HHA. The hospital
should not list the SNF and HHA on its application, as they are not locations where the hospital furnishes
services. They are providers that are separate and distinct from the hospital, and will be reported on their
respective CMS-855A applications.
• Community Mental Health Centers (CMHCs) must report all alternative sites where core services are
provided (proposed alternative sites for initial enrollment and actual alternative sites for those CMHCs
already participating in Medicare). In accordance with provisions of the Public Health Service Act, a CMHC
is required to provide mental health services principally to individuals who reside in a defined geographic
area (service area). Therefore, CMHCs must service a distinct and definable community. Those CMHCs
operating or proposing to operate outside of this specific community must have a separate provider
agreement/number, submit a separate enrollment application, and individually meet the requirements
to participate. CMS will determine if the alternative site is permissible or whether the site must have a
separate agreement/number. CMS will consider the actual demonstrated transportation pattern of CMHC
clients within the community to ensure that all core services and partial hospitalization services are
available from each location within the community. A CMHC patient must be able to access and receive
services he/she needs at the parent CMHC site or the alternative site within the distinct and definable
community served by the parent.

CMS-855A (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
Base of Operations Address
If this provider does not have a physical location where equipment and/or vehicles are stored or from
where personnel report on a regular basis, complete this section with information about the location of the
dispatcher/scheduler. This situation may occur if the provider operates mobile units that travel continuously
from one location directly to another.
NOTE: HHAs must complete this section.

Mobile Facility and/or Portable Units
A “mobile facility” is generally a mobile home, trailer, or other large vehicle that has been converted,
equipped, and licensed to render health care services. These vehicles usually travel to local shopping centers or
community centers to see and treat patients inside the vehicle.
A “portable unit” is when the provider transports medical equipment to a fixed location (e.g., a physician’s
office or nursing home) to render services to the patient.
The most common types of mobile facilities/portable units are portable x-ray suppliers, portable
mammography, and mobile clinics.

If you operate a mobile facility or portable unit, provide the address for the “Base of Operations” as well as
the vehicle information and the geographic area serviced by these facilities or units.

CMS-855A (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
A. PRACTICE LOCATION INFORMATION

Report all practice locations where services will be furnished. If there is more than one location, copy and
complete this section for each.

If you are changing information about a currently reported practice location or adding or removing practice
location information, check the applicable box, furnish the effective date, and complete the appropriate fields
in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name, if applicable)
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)
Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number (if applicable)

State
Fax Number (if applicable)

Medicare Identification Number for this location—CCN (if issued)

ZIP Code + 4

E-mail Address (if applicable)
National Provider Identifier (NPI)

Is this your primary practice location? ...........................................................................................................................
Date you saw or will see your first Medicare patient at this practice location (mm/dd/yyyy)

Yes

CLIA Number for this location (if applicable)
Attach a copy of the most current CLIA certifications for each practice location(s) reported on this application.
FDA/Radiology (Mammography) Certification Number for this location (if issued)
Attach a copy of the most current FDA certifications for each practice location(s) reported on this application.

HHAs only

Is the practice location reported in section 4A an HHA Branch? ......................................................................

CMS-855A (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
Hospitals only (Identify type of practice location)
Identify the type of practice location reported in section 4A. If you are an outpatient provider-based
department (PBD) site that provides services in hospital outpatient departments that are integrated with a
hospital, select the PBD site option and specify the PBD type below.
Main/Primary Hospital Location
Hospital Psychiatric Unit
Hospital Rehabilitation Unit
Hospital Swing-Bed Unit
Outpatient Physical Therapy Extension Site
Other Hospital Practice Location:
(Identify below:)

Outpatient Provider-Based Department (PBD) Site
(Check PBD Type below):
On the “campus” of the main provider (as
defined at 42 CFR 413.65(a)(2))
Remote location of a hospital (as defined at 42
CFR section 413.65(a)(2))
Dedicated emergency department (ED) (as
described at 42 CFR section 489.24(b))
Off-campus of the main provider (does not satisfy
the definition of “campus” at 42 CFR 413.65(a)
(2))
Excepted off-campus (as defined at 42 CFR
419.48(b)).
Excepted off-campus temporarily or permanently
because of re-location due to extraordinary
circumstances outside of the hospital’s control
(as defined at 42 CFR 419.48(b)).
Mobile Facility or Portable Unit

B. REMITTANCE NOTICES/SPECIAL PAYMENTS MAILING ADDRESS

Furnish an address where remittance notices and special payments should be sent for services rendered at the
practice location reported in Section 4A. Please note that payments will be made in the name of the business
reported in Section 4A.
Medicare will issue all routine payments via EFT. Since payments will be made by EFT, the special payments
address below should indicate where all other payment information (e.g., remittance notices, non-routine
special payments) should be sent.

• Check here if your Remittance Notice/Special Payments should be mailed to your Primary Practice Location
Address in Section 4A above and skip this section, OR
• Check here if your Remittance Notice/Special Payments should be mailed to your Correspondence Address in
Section 2C and skip this section.
If you are reporting a change to your Remittance Notice/Special Payments Mailing Address, check the box
below and furnish the effective date.
Change

Effective Date (mm/dd/yyyy):

“Special Payments” Address Line 1 (P.O. Box or Street Name and Number)
“Special Payments” Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

CMS-855A (XX/XX)

State

ZIP Code + 4

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
C. MEDICARE BENEFICIARY MEDICAL RECORDS STORAGE ADDRESS

If your Medicare beneficiaries’ medical records are stored at a location other than the Practice Location
Address shown in Section 4A, complete this section with the name and address of the storage location. This
includes the records for both current and former Medicare beneficiaries.

Post Office Boxes and drop boxes are not acceptable as physical addresses where Medicare beneficiaries’
records are maintained. The records must be the provider’s records, not the records of another provider. For
mobile facilities/portable units, the patients’ medical records must be under the provider’s control. If all records
are stored at the practice location reported in Section 4A, check the box below and skip this section.
Records are stored at the Practice Location reported in Section 4A.

If you are adding or removing a storage location, check the applicable box below and furnish the effective
date.
Add

Remove

Effective Date (mm/dd/yyyy):

1. Paper Storage
Name of Storage Facility
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

ZIP Code + 4

2. Electronic Storage
Do you store your patient medical records electronically? .................................................................................

Yes

If yes, identify the service used to store these records below. This can be an in-house software program,
online service, vendor, etc.

Service used to store electronic records

CMS-855A (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
D. BASE OF OPERATIONS ADDRESS FOR MOBILE OR PORTABLE PROVIDERS (LOCATION OF BUSINESS
OFFICE OR DISPATCHER/SCHEDULER)
The base of operations is the location from where personnel are dispatched, where mobile/portable
equipment is stored, and when applicable, where vehicles are parked when not in use.

NOTE: When necessary to report more than one base of operations, copy and complete this section for each
base of operations.

If you are changing information about a currently reported information, check the applicable box, furnish the
effective date, and complete the appropriate fields in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

The “Base of Operations” is the same as the “Practice Location” reported in Section 4A.
Base of Operations Street Address Line 1 (Street Name and Number)
Base of Operations Street Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Telephone Number (if applicable)

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

E. VEHICLE INFORMATION

If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish
the following vehicle information below. Do not provide information about vehicles that are used only to
transport medical equipment (e.g., when the equipment is transported in a van but is used in a fixed setting,
such as a doctor’s office) or ambulance vehicles. If more than three vehicles are used, copy and complete this
section as needed.
For each vehicle, submit a copy of all health care related permits/licenses/registrations.

If you are adding or removing information, check the applicable box, furnish the effective date, and complete
the appropriate fields in this section.

CHECK ONE FOR EACH VEHICLE
Add

Remove

Add

Remove

Add

Remove

TYPE OF VEHICLE
(van, mobile home, trailer, etc.)

VEHICLE IDENTIFICATION
NUMBER

Effective Date (mm/dd/yyyy):

CMS-855A (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
F. GEOGRAPHIC LOCATION FOR MOBILE OR PORTABLE PROVIDERS WHERE THE BASE OF
OPERATIONS AND/OR VEHICLE RENDERS SERVICES

For home health agencies (HHAs) and/or mobile/portable providers, furnish the city/town, county, state/
territory, and zip code for all locations where the HHA and/or mobile/and/or portable services are rendered.

NOTE: If you provide mobile health care services in more than one state/territory and those states/territories
are serviced by different MACs, complete a separate CMS-855A enrollment application for each MAC’s
jurisdiction.

1. Initial Reporting and/or Additions

If you are reporting or adding an entire state/territory, check the box below and specify the state/territory.
Entire State/Territory of

If services are only provided in selected cities/towns or counties, provide the locations below. Only list ZIP codes
if you are not servicing the entire city/town or county.

CITY/TOWN

COUNTY

STATE/TERRITORY

ZIP CODE

2. Deletions

If you are deleting an entire state/territory, check the box below and specify the state/territory.
Entire State/Territory of

If services are provided in selected cities/towns or counties, provide the locations below. Only list ZIP codes if
you are not deleting service in the entire city/town or county.

CITY/TOWN

CMS-855A (XX/XX)

COUNTY

STATE/TERRITORY

ZIP CODE

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
Only organizations should be reported in this section. Individuals should be reported in Section 6.

Complete this section with information about all organizations that have 5 percent or more (direct or
indirect) ownership of, a partnership interest in, and/or managing control of the provider identified
in Section 2B1, as well as information on any adverse legal actions that have been imposed against
that organization. For examples of organizations that should be reported here, visit our Web site:
CMS.gov/MedicareProviderSupEnroll. If there is more than one organization that should be reported, copy
and complete this section for each.
NOTE: It is not necessary for the organization reported in 2B1 to report itself in this section.

The provider must submit an organizational structure diagram/flowchart identifying all the entities listed in
section 5 and their relationships with the provider and each other.
The following ownership interests must be reported in section 5.

1. Direct Ownership Interest
Examples of direct ownership are as follows:
• The provider is a skilled nursing facility that is wholly (100%) owned by Company A. As such, the provider
would have to report Company A in this section.
• A hospice wants to enroll in Medicare. Company X owns 50% of the hospice. Company X would have to be
reported in this section.
In the first example, Company A is considered a direct owner of the skilled nursing facility, in that it actually
owns the assets of the business. Similarly, Company X is a direct owner of the hospice mentioned in the second
example. It has 50% actual ownership of the hospice.

2. Indirect Ownership Interest
Many organizations that directly own a provider are themselves wholly or partly owned by other organizations
(or even individuals). This is often the result of the use of holding companies and parent/ subsidiary
relationships. Such organizations and individuals are considered to be “indirect” owners of the provider. Using
the first example in #1 above, if Company B owned 100% of Company A, Company B is considered to be an
indirect owner of the provider. In other words, a direct owner has an actual ownership interest in the provider
(e.g., owns stock in the business, etc.), whereas an indirect owner has an ownership interest in an organization
that owns the provider.
Consider the following example of indirect ownership:

Example 1: Ownership
LEVEL 3

Individual X

Individual Y

LEVEL 2

Company C

Company B

LEVEL 1

5%
60%
Company A

30%
40%

•
•
•
•
•

Company A owns 100% of the Enrolling Provider
Company B owns 40% of Company A
Company C owns 60% of Company A
Individual X owns 5% of Company C
Individual Y owns 30% of Company B

100%
In this example, Company A (Level 1) is the direct owner of the provider identified in section 2 of this
application. Companies B and C, as well as Individuals X and Y, are indirect owners of the provider. To calculate
ownership shares using the above-cited example, utilize the following steps.
LEVEL 1
The diagram above indicates that Company A owns 100% of the Enrolling Provider. Company A must be
reported.

CMS-855A (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
LEVEL 2
To calculate the percentage of ownership held by Company C of the Enrolling Provider, multiply:
• The percentage of ownership the LEVEL 1 owner has in the Enrolling Provider
MULTIPLIED BY
The percentage of ownership the LEVEL 2 owner has in that LEVEL 1 owner
• Company A, the LEVEL 1 (or direct) owner, owns 100% of the provider. The diagram also indicates that
Company C, a LEVEL 2 owner, owns 60% of Company A. As such, multiply 100% (or 1.0) by 60% (.60). The
result is .60. Therefore, Company C indirectly owns 60% of the provider, and must be reported.
• Repeat the same procedure for Company B, the other LEVEL 2 owner. Because Company B owns 40% of
Company A, multiply this figure by 100% (again, the ownership stake Company A has in the Enrolling
Provider). Company B thus owns 40% of the Enrolling Provider, and must be reported.
This process is continued until all LEVEL 2 owners have been accounted for.

LEVEL 3
To calculate the percentage of ownership that Individual X has in the Enrolling Provider, multiply:
• The percentage of ownership the LEVEL 2 owner has in the Enrolling Provider
MULTIPLIED BY
The percentage of ownership the LEVEL 3 owner has in that LEVEL 2 owner
• Company C owns 60% of the provider. According to the example above, Individual X (Level 3) Owns 5% of
Company C. Therefore, multiply 60% (.60) by 5% (.05), resulting in .03. This means that Individual X owns
3% of the provider and does not need to be reported in this application.
• Repeat this process for Company B, which owns 40% of the provider. The diagram states that Individual
Y (Level 3) owns 30% of Company B. We thus multiply 40% (.40) by 30% (.30). The result is .12, or 12%.
Because Individual Y owns 12% of the provider, Individual Y must be reported in this application (in
Section 6: Individuals).
This process is continued until all owners in LEVEL 3 have been accounted for. This process must be repeated
for Levels 4 and beyond.

3. Mortgage or Security Interest
All entities with at least a 5% mortgage, deed of trust, or other security interest in the provider must be
reported in this section. To calculate whether this interest meets the 5% threshold, use the following formula:
• Dollar amount of the mortgage, deed of trust, or other obligation secured by the provider or any of the
property or assets of the provider
DIVIDED BY
Dollar amount of the total property and assets of the provider
Example: Two years ago, a provider obtained a $20 million loan from Entity X to add a third floor to its facility.
Various assets of the provider secure the mortgage. The total value of the provider’s property and assets is
$100 million.
Using the formula described above, divide $20 million (the dollar amount of the secured mortgage) by $100
million (the total property and assets of the Enrolling Provider). This results in .20, or 20%. Because Entity
X’s interest represents at least 5% of the total property and assets of the Enrolling Provider, Entity X must be
reported in this section.

4. Partnerships
All general and limited partnership interests—regardless of the percentage—must be reported. This includes:
(1) all interests in a non-limited partnership, and (2) all general and limited partnership interests in a limited
partnership.

CMS-855A (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
5. Additional Information on Ownership
All entities that meet any the requirements above must be reported in this section, including, but not
limited to:
• Entities with an investment interest in the provider (e.g., investment firms)
• Private equity company
• Real estate investment trusts
• Banks and financial institutions (e.g., mortgage interests)
• Holding companies
• Trusts and trustees
• Governmental/Tribal Organizations: If a federal, state, county, city or other level of government, or
an Indian tribe, will be legally and financially responsible for Medicare payments received (including
any potential overpayments), the name of that government or Indian tribe must be reported in this
section as “Other ownership or control/interest.” The provider must submit a letter on the letterhead
of the responsible government (e.g., government agency) or tribal organization, which attests that the
government or tribal organization will be legally and financially responsible in the event that there is any
outstanding debt owed to CMS. This letter must be signed by an “authorized official” of the government
or tribal organization who has the authority to legally and financially bind the government or tribal
organization to the laws, regulations, and program instructions of Medicare. See Section 15 for further
information on “authorized officials.”
• Charitable and Religious Organizations: Many non-profit organizations are charitable or religious in nature,
and are operated and/or managed by a Board of Trustees or other governing body. The actual name of
the Board of Trustees or other governing body should be reported in this section as “Other ownership or
control/interest.”
In addition to furnishing the information in this section, the provider must submit:
• An organizational diagram identifying all of the entities listed in this section and their relationships with
the provider and with each other.
• If the provider is a skilled nursing facility, a diagram identifying the organizational structures of all of its
owners, including owners that were not required to be listed in this section or in Section 6.

6. Managing Control
Any organization that exercises operational or managerial control over the provider, or conducts the dayto-day operations of the provider, is a managing organization and must be reported. The organization need
not have an ownership interest in the provider in order to qualify as a managing organization. For instance,
it could be a management services organization under contract with the provider to furnish management
services for the business.

Report the entity under the role of “managing control” if, for instance, an entity:
a. has direct responsibility for the performance of your organization AND
b. is capable of changing the leadership, allocation of resources, or other processes of your organization to
improve performance.

Providers should also report any managing relationship with a management services organization under
contract with the provider to furnish management services for the business. Faculty practice plans, universitybased health systems, hospital outpatient departments, medical foundations, and groups that primarily treat
enrollees of group model HMOs should review this definition of managing control (organizations) carefully to
determine if it applies.

CMS-855A (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
A. ORGANIZATION WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL—IDENTIFICATION
INFORMATION

Not Applicable
If you are changing, adding or removing information about your current ownership interest and/or managing
control information for this organization, check the applicable box, furnish the effective date, and complete
the appropriate fields in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number (if applicable)

State
Fax Number (if applicable)

National Provider Identifier (NPI)

ZIP Code + 4

E-mail Address (if applicable)
Tax Identification Number (Required)

Medicare Identification Number for this location – PTAN (if issued)

Identify the type of ownership and/or managing control the organization identified above has in the provider
identified in Section 2B1 of this application. Check all that apply. Complete all information for each type
of ownership and/or managing control applicable, including the exact percentage of ownership. Combined
percentage totals for direct owners should not exceed one hundred percent.
5% or greater direct ownership interest

Effective Date (mm/dd/yyyy)

Exact percentage of direct ownership this organization has in the provider
%

Was this organization solely created to acquire/buy the provider and/or the provider’s assets? .....
Is this organization itself owned by any other organization or by any individual? ................................

If this organization also provides contracted services to the provider, describe the type of services furnished:

Yes
Yes

No
No

5% or greater indirect ownership interest

Effective Date (mm/dd/yyyy)

Exact percentage of indirect ownership this organization has in the provider
%

If this organization also provides contracted services to the provider, describe the type of services furnished:

CMS-855A (XX/XX)

Yes
Yes

No
No

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
A. ORGANIZATION WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL—IDENTIFICATION
INFORMATION (Continued)
General Partnership interest

Effective Date (mm/dd/yyyy)

Exact percentage of general partnership interest this organization has in the provider
%

If this organization also provides contracted services to the provider, describe the type of services furnished:

Limited Partnership interest

Effective Date (mm/dd/yyyy)

Yes
Yes

No
No

Exact percentage of limited partnership interest this organization has in the provider
%

If this organization also provides contracted services to the provider, describe the type of services furnished:

5% or greater mortgage interest

Effective Date (mm/dd/yyyy)

Yes
Yes

No
No

Exact percentage of mortgage interest this organization has in the provider
%

If this organization also provides contracted services to the provider, describe the type of services furnished:

5% or greater security interest

Effective Date (mm/dd/yyyy)

Yes

Exact percentage of security interest this organization has in the provider
%

If this organization also provides contracted services to the provider, describe the type of services furnished:

CMS-855A (XX/XX)

Yes

Effective Date (mm/dd/yyyy)

Exact percentage of ownership or control/interest this organization has in the provider
%

If this organization also provides contracted services to the provider, describe the type of services furnished:

Operational/Managerial Control

Effective Date (mm/dd/yyyy)

Yes
Yes

No
No

Exact percentage of operational/managerial control this organization has in the provider
%

Was this organization solely created to acquire/buy the provider and/or the provider’s assets? .....
If this organization also provides contracted services to the provider, describe the type of services furnished:

Yes

Other control/interest (please specify):

Effective Date (mm/dd/yyyy)

Exact percentage of ownership or control/interest this organization has in the provider
%

Yes

Chain Home Office

Effective Date (mm/dd/yyyy)

CMS-855A (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
B. TYPE OF ORGANIZATION

Complete this section with information for the organization listed in section 5A.

NOTE: It is important to accurately identify the type of organization below. Please note that you may need to
check “yes” for more than one box below. For example, the ownership or managing control organization
may be a consulting firm and a private equity company.

Federal and/or State Government Type:
Federal
State
City
County
City-County
Hospital District
Other (Specify):

Identify the type of organization. A response is required for each:

Bank or other financial institution ..................................................................................................................................

Yes

Consulting Firm ........................................................................................................................................................................

Yes

Chain Home Office (Complete Section 5C)..................................................................................................................

Holding Company ....................................................................................................................................................................

Investment Firm (other than private equity company)..........................................................................................

Management Services Company.......................................................................................................................................

Medical Provider/Supplier ....................................................................................................................................................
Medical Staffing Company ..................................................................................................................................................

Private Equity Company .......................................................................................................................................................
Real Estate Investment Trust ..............................................................................................................................................

Other (Specify): ______________________ ......................................................................................................................

CMS-855A (XX/XX)

Yes

Yes
Yes
Yes
Yes
Yes
Yes
Yes

No
No
No
No
No
No
No
No

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
C. CHAIN HOME OFFICES ONLY

A Chain Home Office is an entity that provides centralized management and administrative services to
the providers or suppliers under common ownership and common control, such as centralized accounting,
purchasing, personnel services, management direction and control, and other similar services.

If you are a chain home office, the following information will be used to ensure proper reimbursement when
the provider’s year-end cost report is filed with the MAC. For more information on chain organizations, see 42
C.F.R. section 421.404.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

1. Type of Action this Provider is Reporting
CHECK ONE:

SECTIONS TO COMPLETE

Provider in chain is enrolling in Medicare for
the first time (Initial Enrollment or Change of
Ownership).

Complete all of Section 5.

Provider has changed from one chain to another.

Complete Section 5 in full to identify the new chain
home office.

Provider is no longer associated with the chain

The name of provider’s chain home office is
changing (all other information remains the same).

Complete Section 5 identifying the former chain
home office.
Complete Section 5A.

2. Chain Home Office Administrator Information
First Name of Home Office Administrator or CEO

Middle Initial Last Name

Jr., Sr., etc.

Title of Home Office Administrator
Social Security Number

Date of Birth (mm/dd/yyyy)

3. Provider’s Affiliation to the Chain Home Office
Check one:

Joint Venture/Partnership
Managed/Related
Leased
Operated/Related
Wholly Owned
Other (Specify):

CMS-855A (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
D. FINAL ADVERSE LEGAL ACTION

Complete this section for the organization reported in section 5A above. If you need additional information
regarding what to report, please refer to section 3 of this application. All supporting documentation must be
included as described in section 3.
NOTE: If reporting more than one organization, copy and complete sections 5A and 5B for each organization
reported.
1. Has this organization in section 5A above, under any current or former name or business identity, had a
final adverse legal action listed in section 3 of this application imposed against it?
YES – continue below

NO – skip to section 6

2. If yes, report each final adverse legal action, when it occurred, and the federal or state agency or the
court/administrative body that imposed the action.
NOTE: To satisfy the reporting requirement, section 5D must be filled out in its entirety, and all applicable
attachments must be included.

FINAL ADVERSE LEGAL ACTION

CMS-855A (XX/XX)

DATE

ACTION TAKEN BY

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS)
This section is to be completed with information about any individual who has direct or indirect ownership of,
a partnership interest in, and/or managing control of the provider identified in Section 2B1 of this application.
If there is more than one individual, copy and complete this section for each. Note that the provider must
have at least one managing employee.
Only individuals should be reported in this section. Organizations should be reported in Section 5.

If adding, deleting, or changing information on an existing owner, partner, or managing individual, check the
appropriate box, indicate the effective date of the change, complete the appropriate fields in this section, and
sign and date the certification statement.

The following ownership control interests, as they are described in the instructions to Section 5, must be
reported in this section:
• 5% or greater direct ownership interest
• 5% or greater indirect ownership interest
• 5% or greater mortgage or security interest
• All general and limited partnership interests, regardless of the percentage. This includes: (1) all interests in a
non-limited partnership, and (2) all general and limited partnership interests in a limited partnership.
• Officers and directors, if the entity is organized as a corporation.
For more information on these interests, please see Section 5. Note that the diagrams referred to in Section
5(A)(5) of the instructions must include all individuals with any of the ownership interests described above.
All managing employees of the provider must be reported in this section. The term “managing employee”
includes but is not limited to, a general manager, business manager, administrator, director, medical
director, or other individual who exercises operational or managerial control over, or who directly or
indirectly conducts, the day-to-day operations of the provider, either under contract or through some other
arrangement, regardless of whether the individual is a W-2 employee of the provider.

NOTE: If a governmental or tribal organization will be legally and financially responsible for Medicare
payments received (per the instructions for Governmental/Tribal Organizations in Section 5), the provider is
only required to report its managing employees in Section 6. Owners, partners, officers and directors do not
need to be reported, except those who are listed as authorized or delegated officials on this application.

CMS-855A (XX/XX)

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS) (Continued)
A. INDIVIDUAL WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL—IDENTIFYING
INFORMATION

Not Applicable
If you are changing, adding, or removing information about your current ownership interest and/or managing
control information for this individual, check the applicable box, furnish the effective date, and complete the
appropriate fields in this section.
Change

Add

Remove

Effective Date (mm/dd/yyyy):

First Name

Middle Initial Last Name

Jr., Sr., etc.

Title
Social Security Number (SSN) or Individual Tax Identification Number (ITIN)
Telephone Number

Fax Number

Date of Birth (mm/dd/yyyy)

E-mail Address

Identify the type of ownership and/or managing control the individual identified above has in the provider
identified in Section 2B1 of this application. Check all that apply. Complete all information for each type
of ownership and/or managing control applicable, including the exact percentage of ownership. Combined
percentage totals for direct owners should not exceed one hundred percent.
5% or greater direct ownership interest
Effective Date (mm/dd/yyyy)

Exact percentage of direct ownership interest this individual has in the provider
%