Form CMS-855A Medicare Enrollment Application - Institutional Provider

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

CMS-855A- Medicare Enrollment Application Institutional Providers

REH Completion of CMS-855A Change of Information

OMB: 0938-0685

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MEDICARE ENROLLMENT APPLICATION
INSTITUTIONAL PROVIDERS

CMS-855A
Go to page 1 to determine if you are completing the correct application.
Go to page 5 for information on where to mail this completed application.
Go to 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. Continue 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 provider or 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. § 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-855A (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, go to the last page of this application for the
Privacy Act Statement.

ACRONYMS COMMONLY USED IN THIS APPLICATION
•
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•
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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
Skilled Nursing Facilities must complete Attachment 1

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 enrolling with another Medicare
Administrative Contractor (MAC)

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

You are revalidating your Medicare enrollment

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

Skilled Nursing Facilities must complete Attachment 1

Skilled Nursing Facilities must complete Attachment 1
Skilled Nursing Facilities must complete Attachment 1

You are reactivating your Medicare enrollment

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

You are changing your Medicare information

Go to Section 1B

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)
Buyer/New owner: Complete all sections except 2H
and 2I
Skilled Nursing Facilities must complete Attachment 1

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.
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.
Skilled Nursing Facilities must complete Attachment 1

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)
New organization: Complete all sections except 2G
and 2H
Skilled Nursing Facilities must complete Attachment 1

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

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.
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

Required sections

Business identifying information

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.

Final adverse legal actions

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.

Provider specific information

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.

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)

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.

Ownership interest and/or managing control
information (organizations)

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.
Skilled Nursing Facilities must complete Attachment 1

Ownership interest and/or managing control
information (individuals)

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.
Skilled Nursing Facilities must complete Attachment 1

Chain home office information

CMS-855A (XX/XX)

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.

Attachment 1 for Skilled Nursing Facilities

1, 2B1, 3, 13, either 15B (if you are the authorized
official) or 15C (if you are the delegated official), and
Attachment 1.

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 — go to 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
Indian Health Services—Rural Emergency Hospital

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)?.............................................................................................................................

Yes

4. Is the provider a physician-owned hospital (as defined in the special enrollment notes
on page 8)?...............................................................................................................................................

Yes

CMS-855A (XX/XX)

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 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?.....................................................................................................................

Yes

If yes, complete the following:
Date of accreditation (mm/dd/yyyy)

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. Any current or past revocation or suspension of a medical license.
2. Any current or past voluntary surrender of a medical license in lieu of further disciplinary action.
3. Any current or past revocation or suspension of accreditation.
4. 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?............................................................................................................................

Yes

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

Hospices only
Check this box if the practice location listed in Section 4A is one at which the hospice treats patients.

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, complete all fields below.
Legal Business Name as reported to the Internal Revenue Service
Tax Identification Number (TIN)
Address line 1 (street name and number)
Address line 2 (suite, room, apt. #, etc.)
City/town

CMS-855A (XX/XX)

State

ZIP Code + 4

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

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

VEHICLE IDENTIFICATION
NUMBER

Remove

Effective date (mm/dd/yyyy):

Add

Remove

Effective date (mm/dd/yyyy):

Add

Remove

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.
Check here if you are a Skilled Nursing Facility and skip this section. All organizational ownership interest and
managing control information must be reported in Attachment 1.
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:
LEVEL 3
LEVEL 2
LEVEL 1

Individual X

Individual Y

30%

Company C

Company B

60%

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

Company A
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 “Other 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. Go to 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
“other 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.

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 (TIN)

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?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

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

5% or greater indirect ownership interest
Effective date (mm/dd/yyyy)

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

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

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

CMS-855A (XX/XX)

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

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

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

Limited partnership interest
Effective date (mm/dd/yyyy)

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

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

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)

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

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

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)

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)

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

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

Is this organization itself owned by any other organization or by any individual?.................................

Yes

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

Operational/Managerial control
Effective date (mm/dd/yyyy)

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?......

Yes

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

Other control/interest (please specify):
Effective date (mm/dd/yyyy)

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

Was this organization solely created to acquire/buy the provider and/or the provider’s assets?......

Yes

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

Chain home office
Effective date (mm/dd/yyyy)

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:

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.

Definitions
• Private equity company (for Medicare purposes): A publicly traded or non-publicly traded company that
collects capital investments from individuals or entities (like investors) and purchases a direct or indirect
ownership share of a provider (like a SNF or home health agency).
• Real estate investment trust (for Medicare purposes): For purposes of this application, a real estate
investment trust as defined in 26 U.S.C. § 856.
• Holding company: A business entity, usually a corporation or limited liability company (LLC), created to hold
the controlling stock or membership interests in other companies.
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.

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)
Identify the business structure: (check one)
Corporation
Limited Liability Company
Partnership (general or limited)
Individual
Other (specify):

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

Chain home office (complete Section 5C).....................................................................................................................

Yes

Consulting firm..........................................................................................................................................................................

Yes

Holdingc ompany.....................................................................................................................................................................

Yes

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

Yes

Management services company.........................................................................................................................................

Yes

Medical provider/supplier.....................................................................................................................................................

Yes

Medical staffing company....................................................................................................................................................

Yes

Private equity company.........................................................................................................................................................

Yes

Real estate investment trust................................................................................................................................................

Yes

Other (specify): ______________________........................................................................................................................

Yes

CMS-855A (XX/XX)

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, go to
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 is no longer associated with the chain

Complete Section 5 identifying the former chain
home office.

Provider has changed from one chain to another.

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

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

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.
Check here if you are a Skilled Nursing Facility and skip this section. All individual ownership interest and
managing control information must be reported in Attachment 1.
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 go to 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
%

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

5% or greater indirect ownership interest
Effective date (mm/dd/yyyy)

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

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

5% or greater mortgage interest
Effective date (mm/dd/yyyy)

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

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

CMS-855A (XX/XX)

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

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

General partnership interest
Effective date (mm/dd/yyyy)

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

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

Limited partnership interest
Effective date (mm/dd/yyyy)

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

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

Corporate officer
Effective date (mm/dd/yyyy)

Exact percentage of control as an officer this individual has in the provider
%

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

CMS-855A (XX/XX)

Exact percentage of control as a director this individual has in the provider
________%

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

W-2 managing employee
Effective date (mm/dd/yyyy)

Exact percentage of management control this individual has in the provider
________%

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

HOSPICES ONLY: Check the applicable box if the W-2 managing employee reported in Section 6A is the
hospice’s medical director or administrator:
Hospice medical director
Hospice administrator
Contracted managing employee
Effective date (mm/dd/yyyy)

Exact percentage of this contracted managing employee’s control in the provider
________%

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

HOSPICES ONLY: Check the applicable box if the contracted managing employee reported in Section 6A is the
hospice’s medical director or administrator:
Hospice medical director
Hospice administrator
Other ownership or control/interest (please specify):
Effective date (mm/dd/yyyy)

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

If applicable, furnish this individual’s title:
If this individual also provides contracted services to the provider, describe the type of services furnished:

CMS-855A (XX/XX)

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS) (Continued)
B. FINAL ADVERSE LEGAL ACTION
Complete this section for the individual reported in Section 6A 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 individual, copy and complete Sections 6A and 6B for each individual
reported.
1. Has the individual in Section 6A 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 him/her?
YES – continue below
NO – skip to Section 8
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 6B must be filled out in its entirety, and all applicable
attachments must be included.

FINAL ADVERSE LEGAL ACTION

DATE

ACTION TAKEN BY

SECTION 7: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)

CMS-855A (XX/XX)

SECTION 8: BILLING AGENCY INFORMATION
Applicants that use a billing agency/agent must complete this section. A billing agency/agent is a company or
individual that you contract with to prepare and/or submit your claims. If you use a billing agency/agent, you
remain responsible for the accuracy of the claims submitted on your behalf.
NOTE: The billing agency/agent address cannot be the correspondence mailing address completed in Section
2C of this application.
Check here if this section does not apply and skip to Section 10.

BILLING AGENCY/AGENT NAME AND ADDRESS
If you are changing information about your current billing agency/agent or adding or removing billing agency/
agent 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):

Legal Business Name as reported to the Internal Revenue Service or individual name as reported to the Social Security Administration
If billing agent: date of birth (mm/dd/yyyy)
Billing agency Tax Identification Number or Billing Agent Social Security Number
Billing agency/agent “Doing business as” name (if applicable)
Billing agency/agent address line 1 (street name and number)
Billing agency/agent address line 2 (suite, room, apt. #, etc.)
City/town
Telephone number

State
Fax number (if applicable)

ZIP Code + 4

E-mail address (if applicable)

SECTION 9: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)

CMS-855A (XX/XX)

SECTION 10: OPIOID TREATMENT PROGRAM PERSONNEL
All Opioid Treatment Programs enrolling in the Medicare program must complete this section.

Information for individuals legally authorized to order and/or dispense controlled substances at
OTP facility
The OTP must include the following information for all employees (whether W-2 or not) and contracted staff
who are legally authorized to order and/or dispense controlled substances, whether or not the individual is
currently ordering and/or dispensing at the OTP facility.
Ordering personnel
• First, last name, middle initial (if applicable)
• Date of birth
• Social Security Number (SSN)
• Practitioner type
• Active and valid NPI
• License number
Dispensing personnel
• First, last name, middle initial (if applicable)
• Date of birth
• Social Security Number (SSN)
• Practitioner type
• Active and valid NPI
• License number
Adverse history and ineligibility
Under the OTP Standards in 42 C.F.R section 424.67, an OTP provider must not employ, as a W2 employee or
not, or contract with anyone who meets any of the ineligibility criteria outlined below, whether or not the
individual is currently ordering or dispensing at the OTP facility.
• Currently is revoked from Medicare under 42 C.F.R. section 424.535 or any other applicable section in Title
42, and under an active reenrollment bar.
• Currently is on the CMS preclusion list pursuant to 42 C.F.R. section 422.222 or section 423.120.
• Currently is excluded by the Department of Health and Human Services (DHHS) Office of Inspector General
(OIG).
• Has a prior action, including, but not limited to, a reprimand, fine, or restriction, by a state oversight board
for professional misconduct issues relating to patient harm.

CMS-855A (XX/XX)

SECTION 10: OPIOID TREATMENT PROGRAM PERSONNEL (Continued)
A. ORDERING PERSONNEL IDENTIFICATION
NOTE: Copy and complete this section if more than three OTP ordering personnel need to be reported.
If you are changing information about currently reported OTP ordering personnel or adding or removing OTP
personnel, 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 of OTP ordering personnel

Middle initial

Last name of OTP ordering personnel

Social Security Number (SSN)

Date of birth (mm/dd/yyyy)

NPI

License number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner type

If you are changing information about currently reported OTP ordering personnel or adding or removing OTP
personnel, 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 of OTP ordering personnel

Middle initial

Last name of OTP ordering personnel

Social Security Number (SSN)

Date of birth (mm/dd/yyyy)

NPI

License number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner type

If you are changing information about currently reported OTP ordering personnel or adding or removing
OTP personnel, 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 of OTP ordering personnel

Middle initial

Last name of OTP ordering personnel

Social Security Number (SSN)

Date of birth (mm/dd/yyyy)

NPI

License number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner type

CMS-855A (XX/XX)

SECTION 10: OPIOID TREATMENT PROGRAM PERSONNEL (Continued)
B. DISPENSING PERSONNEL IDENTIFICATION
NOTE: Copy and complete this section if more than three OTP dispensing personnel need to be reported.
If you are changing information about currently reported OTP dispensing personnel or adding or removing
OTP personnel, 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 of OTP dispensing personnel Middle initial

Last name of OTP dispensing personnel

Social Security Number (SSN)

Date of birth (mm/dd/yyyy)

NPI

License number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner type

If you are changing information about currently reported OTP dispensing personnel or adding or removing
OTP personnel, 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 of OTP dispensing personnel Middle initial

Last name of OTP dispensing personnel

Social Security Number (SSN)

Date of birth (mm/dd/yyyy)

NPI

License number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner type

Add

Remove Effective date (mm/dd/yyyy):

First name of OTP dispensing personnel Middle initial

Last name of OTP dispensing personnel

Social Security Number (SSN)

Date of birth (mm/dd/yyyy)

NPI

License number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner type

SECTION 11: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)

CMS-855A (XX/XX)

SECTION 12: SPECIAL REQUIREMENTS FOR HOME HEALTH AGENCIES (HHAs)
Instructions
All HHAs enrolling in the Medicare program must complete this section.
HHAs initially enrolling in Medicare, Medicaid, or both programs on or after January 1, 1998 are required to
provide documentation supporting that they have sufficient initial reserve operating funds (capitalization)
to operate the HHA in the Medicare and/or Medicaid program(s) at the time of application, at all times
during the enrollment process, and for three (3) months after billing privileges have been conveyed. The
capitalization requirement applies to all HHAs enrolling in the Medicare program, including HHAs currently
participating in the Medicare program that, as a result of a change of ownership, will be issued a new
provider number. The capitalization requirement does not apply to a branch of an HHA. Regulations found
at 42 C.F.R. section 489.28 require that the MAC determine the required amount of reserve operating funds
needed for the enrolling HHA by comparing the enrolling HHA to at least three other new HHAs that it serves
which are comparable to the enrolling HHA. Factors to be considered are geographic location, number of
visits, type of HHA, and business structure of the HHA. The MAC then verifies that the enrolling HHA has the
required funds. To assist the MAC in determining the amount of funds necessary, the enrolling HHA should
complete this section.
Check here if this section does not apply and skip to Section 13.

A. HOME HEALTH AGENCY
1. Type of Home Health Agency (check one):
Non-profit agency
Proprietary agency
2. Projected number of visits by this Home Health Agency
How many visits does this HHA project it will make in the first:
• Three months of operation?
• Twelve months of operation?
3. Financial documentation
In order to expedite the enrollment process, the HHA may attach a copy of its most current savings, checking,
or other financial statement(s) that verifies the initial reserve operating funds, accompanied by:
• An attestation from an officer of the bank or other financial institution stating that the funds are in the
account(s) and are immediately available for the HHA’s use, and
• Certification from the HHA attesting that at least 50% of the reserve operating funds are non- borrowed
funds.
Will the HHA be submitting the above documentation with this application?.........................................

Yes

NOTE: The MAC may require a subsequent attestation that the funds are still available. If the MAC determines
that the HHA requires funds in addition to those indicated on the originally submitted account statement(s), it
will require verification of the additional amount as well as a new attestation statement.

4. Additional information
Provide any additional documentation necessary to assist the MAC or state agency in properly comparing this
HHA with other comparable HHAs. Use this space to explain or justify any unique financial situations of this
HHA that may be helpful in determining the HHA’s compliance with the capitalization requirements.

CMS-855A (XX/XX)

SECTION 12: SPECIAL REQUIREMENTS FOR HOME HEALTH AGENCIES (HHAs)
(Continued)

B. NURSING REGISTRIES
If you are changing information about your current nursing registries or adding or removing nursing registries
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):

Does this HHA contract with a nursing registry whereby the latter furnishes personnel to perform HHA services
on behalf of the provider?
YES – Furnish the information below
NO – Skip to section 13
Legal Business/Individual Name as reported to the Internal Revenue Service
Tax Identification Number (TIN)
“Doing business as” name (if applicable)
Billing street address line 1 (street name and number)
Billing street address line 2 (suite, room, apt. #, etc.)
City/town

State

Telephone number

Fax number (if applicable)

ZIP Code + 4

E-mail address (if applicable)

SECTION 13: CONTACT PERSON
If questions arise during the processing of this application, your designated MAC will contact the individual
reported below.
Change
First name

Add

Remove Effective date (mm/dd/yyyy):
Middle initial

Last name

Suffix (e.g., Jr., Sr., M.D., etc.)

Contact person address line 1 (street name and number)
Contact person address line 2 (suite, room, apt. #, etc.)
City/town
Telephone number

State
Fax number (if applicable)

ZIP Code + 4

E-mail address (if applicable)

NOTE: The contact person listed in this section will only be authorized to discuss issues concerning this or any
other enrollment application. Your designated MAC will not discuss any other Medicare issues about you with
the above contact person.

CMS-855A (XX/XX)

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION
This section explains the penalties for deliberately furnishing false information in this application to gain or
maintain enrollment in the Medicare program.
1. 18 U.S.C. section 1001 authorizes criminal penalties against an individual who, in any matter within the
jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals
or covers up by any trick, scheme or device a material fact, or makes any false, fictitious, or fraudulent
statements or representations, or makes any false writing or document knowing the same to contain
any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to
$250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of
up to $500,000 (18 U.S.C. section 3571). Section 3571(d) also authorizes fines of up to twice the gross gain
derived by the offender if it is greater than the amount specifically authorized by the sentencing statute.
2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual who,
“knowingly and willfully,” makes or causes to be made any false statement or representation of a
material fact in any application for any benefit or payment under a federal health care program. The
offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.
3. The Civil False Claims Act, 31 U.S.C. Section 3729, imposes civil liability, in part, on any person who, with
actual knowledge, deliberate ignorance or reckless disregard of truth or falsity (a) presents or causes
to be presented to the United States Government or its contractor or agent a false or fraudulent claim
for payment or approval; (b) uses or causes to be used a false record or statement material either to a
false or fraudulent claim or to an obligation to pay the Government; (c) conceals or improperly avoids
or decreases an obligation to pay or transmit money or property to the Government; or (d) conspires
to violate any provision of the False Claims Act. The False Claims Act imposes a civil penalty of between
$5,000 and $10,000 per violation, as adjusted for inflation by the Federal Civil Penalties Inflation
Adjustment Act, 28 U.S.C. 2461, plus three times the amount of damages sustained by the Government.
4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including an
organization, agency or other entity) that knowingly presents or causes to be presented to an officer,
employee, or agent of the United States, or of any department or agency thereof, or of any State
agency…a claim…that the Secretary determines is for a medical or other item or service that the person
knows or should know:
a. was not provided as claimed; and/or
b. the claim is false or fraudulent.
This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment
of up to three times the amount claimed, and exclusion from participation in the Medicare program and
State health care programs.
5. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care
benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme,
or device a material fact; or makes any materially false, fictitious, or fraudulent statements or
representations, or makes or uses any materially false, fictitious, or fraudulent statement or entry, in
connection with the delivery of or payment for health care benefits, items or services. The individual shall
be fined or imprisoned up to 5 years or both.
6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute, or
attempt, to execute a scheme or artifice to defraud any health care benefit program, or to obtain, by
means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by or under the control of any, health care benefit program in connection with the delivery of
or payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up to 10
years or both. If the violation results in serious bodily injury, an individual will be fined or imprisoned up
to 20 years, or both. If the violation results in death, the individual shall be fined or imprisoned for any
term of years or for life, or both.
7. The United States Government may assert common law claims such as “common law fraud,” “money
paid by mistake,” and “unjust enrichment.” Remedies include compensatory and punitive damages,
restitution, and recovery of the amount of the unjust profit.

CMS-855A (XX/XX)

SECTION 15: CERTIFICATION STATEMENT
An AUTHORIZED OFFICIAL is defined as an appointed official (for example, chief executive officer, chief
financial officer, general partner, chairman of the board, or direct owner) to whom the organization has
granted the legal authority to enroll it in the Medicare program, to make changes or updates to the
organization’s status in the Medicare program, and to commit the organization to fully abide by the statutes,
regulations, and program instructions of the Medicare program.
A DELEGATED OFFICIAL is defined as an individual who is delegated by an authorized official the authority
to report changes and updates to the provider’s enrollment record. A delegated official must be an individual
with an “ownership or control interest” in (as that term is defined in section 1124(a)(3) of the Social Security
Act), or be a W-2 managing employee of the provider.
Delegated officials may not delegate their authority to any other individual. Only an authorized official
may delegate the authority to make changes and/or updates to the provider’s Medicare status. Even when
delegated officials are reported in this application, an authorized official retains the authority to make
any such changes and/or updates by providing his or her printed name, signature, and date of signature as
required in section 15B.
NOTE: Authorized officials and delegated officials must be reported in section 6, either on this application or
on a previous application to this same MAC. If this is the first time an authorized and/or delegated official has
been reported on the CMS-855A, you must complete Section 6 for that individual and that individual must sign
section 15.
By his/her signature(s), an authorized official binds the provider to all of the requirements listed in the
Certification Statement and acknowledges that the provider may be denied entry to or revoked from the
Medicare program if any requirements are not met.
Only an authorized official has the authority to sign (1) the initial enrollment application on behalf of the
provider and (2) add or remove additional authorized officials and delegated officials. Once the delegation
of authority has been established all other enrollment application submissions can be signed by either an
authorized official or delegated official.
By signing this application, an authorized official agrees to immediately notify the MAC if any information
furnished on this application is not true, correct, or complete. In addition, an authorized official, by his/her
signature, agrees to notify the MAC of any future changes to the information contained in this form after the
provider is enrolled in Medicare, in accordance with the timeframes established in 42 C.F.R. section 424.516.
The provider can have as many authorized officials as it wants. If the provider has more than two authorized
officials, it should copy and complete this section as needed.
EACH AUTHORIZED AND DELEGATED OFFICIAL MUST HAVE AND DISCLOSE HIS/HER SOCIAL SECURITY
NUMBER.

CMS-855A (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
A. ADDITIONAL REQUIREMENTS FOR MEDICARE ENROLLMENT
These are additional requirements that the provider must meet and maintain in order to bill the Medicare
program. Read these requirements carefully. By signing, the provider is attesting to having read the
requirements and understanding them.
By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in Section
15D agree to adhere to the following requirements stated in this Certification Statement:
1. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the
Medicare contractor of any future changes to the information contained in this application in accordance
with the time frames established in 42 C.F.R. section 424.516. I understand that any change in the
business structure of this provider may require the submission of a new application.
2. I have read and understand the Penalties for Falsifying Information, as printed in this application. I
understand that any omission, misrepresentation, or falsification of any information contained in this
application or contained in any communication supplying information to Medicare, or any alteration of
any text on this application form, may be punished by criminal, civil, or administrative penalties including,
but not limited to, the denial or revocation of Medicare billing privileges, and/or the imposition of fines,
civil damages, and/or imprisonment.
3. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to
the organization listed in section 2B1 of this application. The Medicare laws, regulations, and program
instructions are available through the Medicare Administrative Contractor. I understand that payment
of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with
such laws, regulations, and program instructions (including, but not limited to, the Federal Anti-Kickback
Statute, 42 U.S.C. section 1320a-7b(b) (section 1128B(b) of the Social Security Act) and the Physician SelfReferral Law (Stark Law), 42 U.S.C. section 1395nn (Section 1877 of the Social Security Act)).
4. Neither this provider, nor any five percent or greater owner, partner, officer, director, managing
employee, authorized official, or delegated official thereof is currently sanctioned, suspended, debarred,
or excluded by Medicare, a state health care program, e.g., Medicaid program, or any other federal
program, or is otherwise prohibited from supplying services to Medicare or other federal program
beneficiaries.
5. I agree that any existing or future overpayment made to the provider by the Medicare program may be
recouped by Medicare through the withholding of future payments.
6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by
Medicare, and I will not submit claims with deliberate ignorance or reckless disregard of their truth or
falsity.
7. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting
the Medicare program participation requirements, to release to any authorized representative, employee,
or agent of the Centers for Medicare & Medicaid Services (CMS), a copy of my most recent accreditation
survey, together with any information related to the survey that CMS may require (including corrective
action plans).

CMS-855A (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
B. AUTHORIZED OFFICIAL SIGNATURE(S)
1. 1st Authorized official signature
I have read the contents of this application. My signature legally and financially binds this provider to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete and I authorize the MAC to verify this information.
If I become aware that any information in this application is not true, correct, or complete, I agree to notify
the MAC of this fact in accordance with the time frames established in 42 C.F.R. section 424.516.
If you are adding or removing an authorized official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add

Remove Effective date (mm/dd/yyyy):

Authorized official’s information and signature
First name

Middle initial

Telephone number

Title/position

Last name

Authorized official signature (first, middle, last name, Jr., Sr., M.D., etc.)

Suffix (e.g., Jr., Sr., M.D., etc.)

Date signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

2. 2nd Authorized official signature
I have read the contents of this application. My signature legally and financially binds this provider to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete and I authorize the MAC to verify this information.
If I become aware that any information in this application is not true, correct, or complete, I agree to notify
the MAC of this fact in accordance with the time frames established in 42 C.F.R. section 424.516.
If you are adding or removing an authorized official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add

Remove Effective date (mm/dd/yyyy):

Authorized official’s information and signature
First name

Middle initial

Telephone number

Title/position

Last name

Authorized official signature (first, middle, last name, Jr., Sr., M.D., etc.)

Suffix (e.g., Jr., Sr., M.D., etc.)

Date signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

CMS-855A (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
C. ADDITIONAL REQUIREMENTS FOR MEDICARE ENROLLMENT FOR DELEGATED OFFICIALS
NOTE: Delegated officials are optional.
• You are not required to have a delegated official. However, if no delegated official is assigned, the
authorized official(s) will be the only person(s) who can make changes and/or updates to the provider’s
status in the Medicare program.
• The signature of a delegated official shall have the same force and effect as that of an authorized official,
and shall legally and financially bind the provider to the laws, regulations, and program instructions of
the Medicare program. By his or her signature, the delegated official certifies that he or she has read the
certification statement in Section 15 and agrees to adhere to all of the stated requirements. A delegated
official also certifies that he/she meets the definition of a delegated official. When making changes and/or
updates to the provider’s enrollment information maintained by the Medicare program, a delegated official
certifies that the information provided is true, correct, and complete.
• Delegated officials being removed do not have to sign or date this application.
• Independent contractors are not considered “employed” by the provider and therefore, cannot be
delegated officials.
• The signature(s) of an authorized official in Section 15B constitutes a legal delegation of authority to all
delegated official(s) assigned in Section 15D.
• If there are more than two individuals, copy and complete this section for each individual.

D. DELEGATED OFFICIAL SIGNATURE(S)
1. 1st Delegated official signature
If you are adding or removing a delegated official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add

Remove Effective date (mm/dd/yyyy):

Delegated official’s information and signature
Delegated official first name

Middle initial

Last name

Suffix (e.g., Jr., Sr., M.D., etc.)

Delegated official signature (first, middle, last name, Jr., Sr., M.D., etc.)

Check here if delegated official is a W-2 employee

Date signed (mm/dd/yyyy)
Telephone number

Authorized official’s signature assigning this delegation (first, middle, last name, Jr., Sr., M.D., etc.)

Date signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

CMS-855A (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
2. 2nd Delegated official signature
If you are adding or removing a delegated official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add

Remove Effective date (mm/dd/yyyy):

Delegated official’s information and signature
Delegated official first name

Middle initial

Last name

Suffix (e.g., Jr., Sr., M.D., etc.)

Delegated official signature (first, middle, last name, Jr., Sr., M.D., etc.)

Check here if delegated official is a W-2 employee

Date signed (mm/dd/yyyy)
Telephone number

Authorized official’s signature assigning this delegation (first, middle, last name, Jr., Sr., M.D., etc.)

Date signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

SECTION 16: FOR FUTURE USE (THIS SECTION NOT APPLICABLE)

CMS-855A (XX/XX)

SECTION 17: SUPPORTING DOCUMENTATION INFORMATION
This section lists the documents that, if applicable, must be submitted with this completed enrollment
application. If you are enrolling for the first time, or reactivating or revalidating your enrollment, you must
submit all applicable documents. When reporting a change of information, only submit documents that apply
to the change reported. Your designated Medicare Administrative Contractor (MAC) may request, at any time
during the enrollment process, documentation to support or validate information reported on this application.
In addition, your designated MAC may also request documents from you other than those identified in this
section as are necessary to ensure correct billing of Medicare.
Licenses, certifications and registrations required by Medicare or State law.
Federal, State/Territory, and/or local (city/county) business licenses, certifications and/or registrations required
to operate a health care facility.
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name
(e.g., IRS CP 575) provided in section 2A.
Completed Form CMS-588, Authorization Agreement for Electronic Funds Transfer. Include a voided check or
bank letter.
NOTE: If a provider already receives payments electronically and is not making a change to its banking
information, the CMS-588 is not required.
Copy(s) of all bills of sale or sales agreements for all ownership changes. This includes, CHOWS, Acquisition/
Mergers, Consolidations, and all other ownership changes that are required to be reported, regardless of the
percentage involved (e.g., new 15 percent owner).
Copy(s) of all documents that demonstrate meeting capitalization requirements (HHAs only).
If Medicare payment due a provider of services is being sent to a bank (or similar financial institution)
with whom the provider has a lending relationship (that is, any type of loan), the provider must provide a
statement in writing from the bank (which must be in the loan agreement) that the bank has agreed to waive
its right of offset for Medicare receivables.
Copy(s) of all final adverse legal action documentation (e.g., notifications, resolutions, and reinstatement
letters).
Copy of an attestation for government entities and tribal organizations.
Copy of HRSA Notice of Grant Award if that is a qualifying document for FQHC status.
Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit (e.g., IRS Form 501(c)(3)).
Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified
as a Disregarded Entity (e.g., Form 8832, if applicable).
NOTE: A disregarded entity is an eligible entity that is not treated as a separate entity from its single owner
for income tax purposes.
Organizational structure diagram/flowchart identifying all of the entities listed in section 5 and their
relationships with the provider and each other.
Copy of all mobile vehicle registrations (all mobile services).
Rural Emergency Hospital (REH) Action Plan.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information
collection is 0938-0685. Various sections of the Social Security Act, the United States Code (U.S.C.), Internal Revenue Service (IRS) Code and
the CFR require providers and suppliers to furnish information concerning the amounts due and the identification of individuals or entities
that furnish medical services to beneficiaries before payment can be made. The CMS-855A application collects this information, including
the data required to uniquely identify and enumerate the provider/supplier. Additional information needed to process claims accurately
and timely is also collected on the application. The data collection helps CMS ensure that the provider or supplier meets all statutory and
regulatory requirements, and providers and suppliers must complete the CMS-855A application to obtain and retain the ability to receive
Medicare payments consistent with Section 1866(j) of the Social Security Act.
The time required to complete this information collection is estimated at 6 hours per response, including the time to review instructions,
search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,
Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850 or e-mail [email protected].
CMS will comply with all Privacy Act, Freedom of Information laws, and regulations that apply to this collection. Privileged or confidential
commercial or financial information is protected from public disclosure by federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection
burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please visit CMS.gov/Medicare/Provider-Enrollment-and-Certification.
CMS-855A (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES
All skilled nursing facilities (SNFs) must complete this attachment with their application during:
• Initial enrollment
• Revalidation
• Change of information (though only with respect to the information that is changing)
• Change of Ownership (CHOW)

ORGANIZATION INSTRUCTIONS
Ownership interest, managing control, additional disclosable party information
• Complete this section to report an organization identified below. Visit CMS.gov/medicare/
enrollment-renewal/providers-suppliers for examples of organizations to report
• Report information on any adverse legal actions that have been imposed against the organization
• To report more than 1 organization, copy and complete this section for each organization
• Don’t report individuals in this section
Submit 2 organizational structure diagrams or flowcharts:
• One chart must identify all the entities listed in Section A and show their relationships with the provider
and each other.
• One chart must identify the organizational structures of all its owners, including owners not listed in this
attachment (e.g., less than 5% direct or indirect owners).

Report these ownership interests in this section:
• Direct ownership interest
A direct owner has an actual ownership interest in the provider itself (e.g., owns stock in the business).
Examples:
• Company A wholly (100%) owns the enrolling SNF provider. The provider would report Company A
because Company A is a direct owner of the SNF and owns the assets of the business.
• Company X owns 50% of the enrolling SNF provider. The provider would report Company X as a direct
owner because Company X has 50% ownership of the SNF.

• Indirect ownership interest
An indirect owner has an ownership interest in an organization that owns the provider or in another
indirect owner. Many organizations that directly own a provider are themselves wholly or partly owned
by other organizations or 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 example above, if Company B owned 100% of Company A, Company B is considered to
be an indirect owner of the provider.
Example:
LEVEL 3
LEVEL 2
LEVEL 1

Individual X

Individual Y

30%

Company C

Company B

60%

40%

Company A

• 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%

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
In this example, Company A (Level 1) is the direct owner of the provider. Companies B and C, as well as
individuals X and Y, are indirect owners of the provider. To calculate ownership shares using the example
above, use these steps:
• Level 1
Company A owns 100% of the enrolling provider. You must report Company A.
• Level 2
To calculate the percentage of ownership held by Company C of the enrolling provider:
• 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 the Level 1 owner.
• Company A, the Level 1 (or direct) owner, owns 100% of the provider. In the diagram Company C,
a Level 2 owner, owns 60% of Company A. Multiply 100% (or 1.0) by 60% (.60). The result is .60.
Company C indirectly owns 60% of the provider. You must report it.
• Repeat this process for Company B, the other Level 2 owner. Because Company B owns 40% of
Company A, multiply this figure by 100% (the ownership stake Company A has in the enrolling
provider). Company B indirectly owns 40% of the enrolling provider. You must report it.
Continue this process until all Level 2 owners are accounted for.
• Level 3
To calculate the percentage of ownership that Individual X has in the enrolling provider:
• 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. In the example above, Individual X (Level 3) owns 5% of
Company C. Multiply 60% (.60) by 5% (.05). The result is .03. Individual X indirectly owns 3% of the
provider, which does not meet the 5% threshold. You do not report it.
• Repeat this process for Company B, which owns 40% of the provider. In the diagram Individual
Y (Level 3) owns 30% of Company B. Multiply 40% (.40) by 30% (.30). The result is .12, or 12%.
Individual Y owns 12% of the provider. You must report it.
Continue this process until all Level 3 owners are accounted for. Repeat this process for Levels 4 and
beyond.

• General and limited partnerships interests
Report all general and limited partnership interests—regardless of the percentage. This includes all
partnership interests in a non-limited partnership, and all general and limited partnership interests in a
limited partnership.
• Mortgage or security interest
Report all entities with at least a 5% mortgage, deed of trust, or other security interest in the SNF. 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 SNF or any of the
property or assets of the SNF divided by dollar amount of the total property and assets of the SNF.
Example: Two years ago, a SNF obtained a $20 million loan from Entity X to add a third floor to its facility.
Various assets of the SNF secure the mortgage. The total value of the SNF’s property and assets is $100
million.
Using the formula above, divide $20 million (the dollar amount of the secured mortgage) by $100 million
(the total property and assets of the Enrolling SNF). This results in .20, or 20%. Entity X must be reported
because their interest represents at least 5% of the total property and assets of the enrolling SNF.

• Operational/managing control
• Any organization that exercises operational, managerial control over the provider, or directly or
indirectly conducts the day-to-day operations of the provider. The organization need not have an
ownership interest in the provider 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.
• Any organization that has direct responsibility for the performance of your organization or can change
the leadership, allocation of resources, or other processes of your organization to improve performance.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
• Any managing relationship with a management services organization under contract with the provider
to furnish management services for the business. Faculty practice plans, university-based 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.

• Additional disclosable party
• Any organization that exercises operational, financial, or managerial control over the facility, provides
policies procedures for any of the operations of the facility, or provides financial or cash management
services to the facility;
• Any organization that leases or subleases real property to the facility, or owns a whole or part interest
equal to or exceeding 5 percent of the total value of such real property; or
• Any organization that provides management or administrative services, management or clinical
consulting services, or accounting or financial services to the facility.
The organizational structure (as that term is defined in section 1124(c)(5)(D) of the Social Security Act)
of each additional disclosable party must be identified in section D of the Organizations portion of this
attachment. This means that the following parties must be reported:
• For ADPs that are corporations: All their 5% or greater direct and indirect owners.
• For ADPs that are LLCs: All their direct and indirect owners (regardless of the percentage) and all their
managing organizations and individuals.
• For ADPs that are general partnerships: All the partners, regardless of the percentage.
• For ADPs that are limited partnerships: All general partners (regardless of the percentage) and all limited
partners with at least a 10 percent interest.
• For ADPs that are trusts: All trustees.
Along with furnishing the above data in section D, the SNF must also submit a diagram of the
organizational structure of each additional disclosable party of the facility. This must include a
written description of the relationship of each such additional disclosable party to the facility and
to all the SNF’s other additional disclosable parties. For examples of organizations to report, visit
CMS.gov/medicare/enrollment-renewal/providers-suppliers.

• Additional ownership interests and/or managing control
The organizations above include, but are not limited to, the following. You must report them in this
attachment:
• Entities with an investment interest in the provider (like investment firms)
• Private equity companies
• Real estate investment trusts
• Banks and financial institutions (like mortgage interests)
• Holding companies
• Trusts and trustees
• Governmental/tribal organizations: Federal, state, county, city, or other level of government, or an
Indian tribe, legally and financially responsible for Medicare payments received (including any potential
overpayments), must report the name of that government or Indian tribe in the applicable section.
The provider must submit a letter on the letterhead of the responsible government (like a government
agency) or tribal organization, which attests that the government or tribal organization will be legally
and financially responsible if 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. Go to 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. Report the
actual name of the Board of Trustees or other governing body in the applicable section.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
A. ORGANIZATION IDENTIFICATION INFORMATION
Check this box if you have no organizations with ownership or managing control to report.
Not Applicable
To change, add, or remove information about the organization, check the applicable box, enter the effective
date, and complete the appropriate fields.
Change

Add

Remove Effective date (mm/dd/yyyy):

Legal Business Name as reported to the Internal Revenue Service (IRS)
“Doing business as” name (if different than Legal Business Name)
Address line 1 (street name and number)
Address line 2 (suite, room, etc.)
City/town

State

ZIP Code + 4

Telephone number

Fax number (if applicable)

E-mail address (if applicable)

National Provider Identifier (NPI)

Tax Identification Number (TIN)

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

B. TYPE OF ORGANIZATION
Complete this section with information for the organization listed in section A.

Definitions
• Private equity company (for Medicare purposes): A publicly traded or non-publicly traded company that
collects capital investments from individuals or entities (like investors) and purchases a direct or indirect
ownership share of a provider (like a SNF or home health agency). (Go to 42 C.F.R. § 424.502.)
• Real estate investment trust (for Medicare purposes): For purposes of this attachment, a real estate
investment trust as defined in 26 U.S.C. § 856. (Go to 42 C.F.R. § 424.502.)
• Holding company: A business entity, usually a corporation or limited liability company (LLC), created to hold
the controlling stock or membership interests in other companies.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
IRS business designation
Identify how your business is registered with the IRS (Check one).
If your business is a federal or state government supplier, check “Non-profit” and specify the level.
Government-owned entities don’t need to provide 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 type of business structure: (check one)
Corporation
Limited Liability Company
Partnership (general or limited)
Sole proprietor
Other (specify):

Federal and/or state government type:
Federal
State
City
County
City-county
Hospital district
Other (specify):

Identify the type of organization.
Answer all questions. You may need to check “yes” for more than 1 box.
Bank or other financial institution...................................................................................................................................

Yes

Chain home office (complete section 3)........................................................................................................................

Yes

Consulting firm..........................................................................................................................................................................

Yes

Corporation.................................................................................................................................................................................

Yes

Holding company.....................................................................................................................................................................

Yes

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

Yes

Limited Liability Company....................................................................................................................................................

Yes

Management services company.........................................................................................................................................

Yes

Medical provider/supplier.....................................................................................................................................................

Yes

Medical staffing company....................................................................................................................................................

Yes

Private equity company.........................................................................................................................................................

Yes

Real estate investment trust................................................................................................................................................

Yes

Trust or trustee..........................................................................................................................................................................

Yes

Other (specify): ______________________........................................................................................................................

Yes

........

Yes

Is this organization the ultimate parent company in a multi-organizational group of entities?......

Yes

Is this organization itself owned by any other organization or individual?................................................

Yes

Answer all questions about your organization. You may need to check “yes” for more than 1 box.
Was this organization solely created to acquire or buy the provider or the provider’s assets?

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
C. CHAIN HOME OFFICES ONLY
If you’re a chain home office, we’ll use the information you provide to ensure proper reimbursement when
the provider files their year-end cost report with the MAC.
For more information on chain organizations, go to 42 C.F.R. section 421.404.
Change

Add

Remove Effective date (mm/dd/yyyy):

1. Type of action this provider is reporting
CHECK ONLY 1:

COMPLETE THIS SECTION

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

Section C

Provider is no longer associated with the chain

Section C (to identify the former chain
home office)

Provider has changed from one chain to another

Section C (to identify the new chain home
office).

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

Section A

2. Chain home office administrator or CEO contact 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: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
D. RELATIONSHIP TO SNF AND/OR TO ADDITIONAL DISCLOSABLE PARTY (ADP) OF SNF
Questions 1–7 should only be completed if it applies to your business structure. Furnish the additional
information, including the Effective date and exact percentage of ownership, if applicable. Combined
percentage totals for direct owners can’t exceed 100%.
1. If the SNF is a corporation
Does the reported organization have a 5% or greater direct ownership interest in the SNF?..........

Yes

Does the reported organization have any direct general or limited partnership/ownership interest
in the SNF regardless of the percentage?..................................................................................................................... Yes
If yes, complete the below fields.

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
________%

2. If the SNF is an LLC
Does the reported organization have any direct ownership interest in the SNF regardless
of the percentage? .................................................................................................................................................................
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

3. If the SNF is a general partnership
Does the reported organization have any direct general partnership/ownership interest
in the SNF regardless of the percentage?.....................................................................................................................
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

4. If the SNF is a limited partnership

Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

5. If the SNF has a business structure not identified in 1–4
Does the reported organization have a 5% or greater direct ownership interest in the SNF?..........

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

6. If the SNF is a business structure other than an LLC, general partnership, or limited partnership
Does the reported organization have a 5% or greater indirect ownership interest in the SNF?......
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
7. If the SNF is an LLC, general partnership, or limited partnership
Does the reported organization have any indirect ownership interest in the SNF regardless of
the percentage? .......................................................................................................................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

Questions 8–13 must be completed regardless of the SNF’s business structure. Include the Effective date and
exact percentage of ownership, if applicable.
8. Does the reported organization have a 5% or greater mortgage or security interest in the SNF?...
No

Yes

If yes, complete the below fields.
Type of interest:
Mortgage

Effective date (mm/dd/yyyy)

Exact percentage of mortgage/security interest

Security

9. Is the reported organization a trustee of the SNF?...........................................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

10. Does the reported organization exercise any of the following types of control, either
directly or indirectly, over the SNF or any part of the SNF? (This includes, but is not limited
to, entities that meet the definition of “managing organization” as defined in § 424.502.)............
If yes, complete the below fields.
Operational:

Yes

No Effective date (mm/dd/yyyy):

Managerial:

Yes

No Effective date (mm/dd/yyyy):

Financial:

Yes

No Effective date (mm/dd/yyyy):

The type(s) of control (e.g., the type and form of financial control):
Which part(s) of the SNF the control applies to:
Whether this control is furnished under contract:

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
11. Does the reported organization provide any of the following—either directly or indirectly—
to the SNF or any part of the SNF ..................................................................................................................................

Yes

If yes, complete the below fields.
Policies or procedures for any
of the SNF’s operations

Yes

Effective date (mm/dd/yyyy):

Financial services

Yes

Effective date (mm/dd/yyyy):

Cash management services

Yes

Effective date (mm/dd/yyyy):

Management services

Yes

Effective date (mm/dd/yyyy):

Administrative services

Yes

Effective date (mm/dd/yyyy):

Clinical consulting services

Yes

Effective date (mm/dd/yyyy):

Accounting services

Yes

Effective date (mm/dd/yyyy):

The type(s) of services (e.g., accounting services and the type/form of the accounting services)
Whether these services are furnished under contract:

12. Does the reported organization lease or sublease real property to the SNF?...................................
If yes, complete the below fields.
The type of lease arrangement and the length of the lease.

13. Does the reported organization directly or indirectly own at least 5 percent of the
total value of the SNF’s real property or the real property on/in which the
SNF operates (e.g., 5 percent of the real property the SNF leases)?..............................................................
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

Whether the ownership is of real property the SNF owns or whether it is of real property the SNF leases or subleases.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
Questions 14–18 ask whether the reported organization has an ownership or trustee interest in any additional
disclosable party (ADP) of the SNF. Each question only applies to a particular ADP organizational type. (For
instance, question 14 only applies to interests in ADPs that are corporations, question 15 only applies to
interests in ADPs that are LLCs, etc.) These questions must be completed for all organizations reported in
section A of this Attachment, regardless of whether the reported organization is itself an ADP. Please review
the instructions to the Attachment for a definition of “Additional disclosable party.” Note that if the SNF
checked “Yes” in question 9, 10, 11, 12, and/or 13 for a particular reported organization, that organization is
considered an ADP.
14. ADPs that are corporations
Is the reported organization a 5% or greater direct or indirect owner of any ADP of the
SNF that is a corporation?....................................................................................................................................................
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of ownership:
Direct Indirect

Yes

Exact percentage of ownership
%

List the corporation ADP(s) of which the organization is an owner (e.g., name of the ADP)

15. ADPs that are LLCs
Does the reported organization have any direct or indirect ownership interest in—or exercises
managing control of—any ADP of the SNF that is an LLC, regardless of the percentage?..................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of ownership:
Direct Indirect

Exact percentage of ownership
%

List the LLC ADP(s) of which the organization is an owner (e.g., name of the ADP)

16. ADPs that are general partnerships
Does the reported organization have any general partnership/ownership interest in any ADP
of the SNF that is a general partnership, regardless of the percentage?......................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of partnership interest
%

List the general partenrship ADP(s) of which the organization is a general partner (e.g., name of the ADP)

17. ADPs that are limited partnerships
Does the reported organization have any general partnership interest (regardless of the percentage)
in any limited partnership ADP of the SNF or at least a 10 percent limited partnership interest
in any ADP of the SNF?.......................................................................................................................................................... Yes
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of partnership interest:
General Limited

Exact percentage of partnership interest
%

List the limited partnership ADP(s) of which the organization is a general or limited partner (e.g., name of the ADP)

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
18. ADPs that are trusts
Is the reported organization a trustee of any ADP of the SNF?........................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)
List the ADP(s) of which the organization is a trustee (e.g., name of the ADP)

19. Owners/Trustees of ADP(s)
Answer this question only if the SNF answered “Yes” to question 14, 15, 16, 17, or 18. For purposes of question
19 ONLY, the term “interest” means any of the interests (ownership, trustee, LLC managerial) listed in the
“organizational structure” definition in section 1124(c)(5)(D) of the Social Security Act. (Go to the instructions
for this definition.)
Does this ADP owner/trustee/LLC manager (as indicated in question 14, 15, 16, 17, or 18)
have any interest in the SNF itself OR in another ADP of the SNF?.................................................................

Yes

If yes, complete the below field.
List the LBN of the entity (i.e., the SNF itself or another ADP of the SNF) in which this ADP owner/trustee/LLC manager has an interest

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
E. FINAL ADVERSE LEGAL ACTION

Complete this section for the organization you reported in section A. For more information on what to report,
go to section 3 of this application. Include all supporting documentation described in section 3.
If you are changing information, check “change” box, furnish the effective date, and complete the
appropriate fields in this section.
Change Effective date (mm/dd/yyyy):
1. Has the organization in section A, under any current or former name or business identity, ever had a final
adverse action listed in section 3 of this application imposed against it?
YES – continue to item 2.
NO – skip to next section.
2. Report each final adverse legal action, when it occurred, and the federal or state agency or the court or
administrative body that imposed the action.

FINAL ADVERSE LEGAL ACTION

DATE

ACTION TAKEN BY

To satisfy the reporting requirement, fill out this section and include all applicable attachments.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
INSTRUCTIONS FOR INDIVIDUALS
Ownership interest, managing control, additional disclosable party information
• Complete this section to report any individuals with direct or indirect ownership of, a partnership
interest in, and/or managing control of the provider identified in Section 2B1 of this application. Visit
CMS.gov/medicare/enrollment-renewal/providers-suppliers for examples of individuals to report
• Report information on any adverse legal actions that have been imposed against the individual
• To report more than 1 individual, copy and complete this section for each
• At least one managing employee must be reported.
• If a governmental or tribal organization will be legally and financially responsible for Medicare payments
received (per the organizational instructions for governmental/tribal organizations), the SNF is only
required to report its managing employees in Section A. Owners, partners, officers and directors do not
need to be reported, except those who are listed as authorized or delegated officials on this application.
• To report organizations, go to the organization section.

Report these ownership control interests in this section:
•
•
•
•
•

Direct ownership interest
Indirect ownership interest
Mortgage or security interest
General and limited partnership interests
Report all general and limited partnership interests—regardless of the percentage. This includes all
interests in a non-limited partnership, and all general and limited partnership interests in a limited
partnership.
• Officers and directors
• If the entity is organized as a corporation.
• Managing employees (for purposes of nursing facilities under section 1124(c))
• An individual, (including a general manager, business manager, administrator, director, or consultant)
who directly or indirectly manages, advises, or supervises any element of the practices, finances, or
operations of the facility. Report all managing employees of the SNF in this section. For purposes of this
definition, this includes, but is not limited to, a hospice or skilled nursing facility administrator and a
hospice or skilled nursing facility medical director.
• Member of the governing body
• Trusts and trustees
• Additional disclosable party:
• Any individual that exercises operational, financial, or managerial control over the facility, provides
policies procedures for any of the operations of the facility, provides financial or cash management
services to the facility;
• Any individual that leases or subleases real property to the facility, or owns a whole or part interest
equal to or exceeding 5 percent of the total value of such real property; or
• Any individual that provides management or administrative services, management or clinical consulting
services, or accounting or financial services to the facility.
The organizational structure (as that term is defined in section 1124(c)(5)(D) of the Social Security Act) of each
additional disclosable party must be identified in section B of the Individuals portion of this attachment. This
means that the following parties must be reported:
• For ADPs that are corporations: All their officers, directors, and 5% or greater direct and indirect owners.
• For ADPs that are LLCs: All their direct and indirect owners (regardless of the percentage) and all their
managing individuals.
• For ADPs that are general partnerships: All the partners, regardless of the percentage.
• For ADPs that are limited partnerships: All general partners (regardless of the percentage) and all limited
partners with at least a 10 percent interest.
• For ADPs that are trusts: All trustees.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
Along with furnishing the above data in Section B, the SNF must also submit a diagram of the
organizational structure of each additional disclosable party of the facility. This must include a
written description of the relationship of each such additional disclosable party to the facility and
to all the SNF’s other additional disclosable parties. For examples of individuals to report, visit
CMS.gov/medicare/enrollment-renewal/providers-suppliers.
For more information on these interests, go to the organization instructions. The diagrams referred to in the
organization instructions must include all individuals with any of the ownership interests described above.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
A. INDIVIDUAL IDENTIFYING INFORMATION
Check this box if you have no individuals with ownership or managing control to report.
Not applicable
To change, add, or remove information about the individual, check the applicable box, enter the effective
date, and complete the appropriate fields.
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 (if applicable)

Date of birth (mm/dd/yyyy)

E-mail address (if applicable)

B. RELATIONSHIP TO SNF AND/OR ADDITIONAL DISCLOSABLE PARTY (ADP) OF SNF
Identify the type of interest the individual in section A has in the SNF.
Questions 1–7 should only be completed if they apply to the SNF’s business structure. Furnish the additional
information, including the effective date and exact percentage of ownership, if applicable. Combined
percentage totals for direct owners can’t exceed 100%.
1. If the SNF is a corporation
Does the reported individual have a 5% or greater direct ownership interest in the SNF?................
Effective date (mm/dd/yyyy)

Yes

Exact percentage of ownership
%

2. If the SNF is an LLC
Does the reported individual have any direct ownership interest in the SNF regardless of the
percentage?.............................................................................................................................................
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

3. If the SNF is a general partnership
Does the reported individual have any direct general partnership/ownership interest in
the SNF regardless of the percentage?.........................................................................................................................
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

4. If the SNF is a limited partnership
Does the reported individual have any direct general or limited partnership/ownership interest
in the SNF regardless of the percentage?....................................................................................................................
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
5. If the SNF has a business structure other than those described in 1–4
Does the reported individual have a 5% or greater direct ownership interest in the SNF?...............

Yes

10. Does the reported individual have a 5% or greater mortgage or security interest in the SNF?. Yes

Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

6. If the SNF is a business structure other than an LLC, general partnership, or limited partnership
Does the reported individual have a 5% or greater indirect ownership interest in the SNF?...........
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

7. If the SNF is a LLC, general partnership, or limited partnership
Does the reported individual have any indirect ownership interest in the SNF regardless of the
percentage?................................................................................................................................................................................
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

8. If the SNF is a corporation
Is the reported individual an officer or director of the SNF?..............................................................................
Effective date (mm/dd/yyyy)

Type of position:
Officer Director

Title

9. If the SNF has a business structure other than that of a corporation
Is the reported individual a member of the SNF’s governing body?...............................................................
Effective date (mm/dd/yyyy)

Type of governing body:

Title

Questions 10–16 must be answered regardless of the SNF’s business structure.

Effective date (mm/dd/yyyy)

Type of interest:
Mortgage

Exact percentage of mortgage/security interest

Security

11. Is the reported individual a trustee of the SNF?...............................................................................................

Yes

Effective date (mm/dd/yyyy)

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
12. Does the reported individual exercise any of the following types of control, either directly
or indirectly, over the SNF or any part of the SNF?............................................................................. Yes
No
(This includes, but is not limited to, entities that meet the definition of “managing organization” as defined in
§ 424.502.)
If yes, complete the below fields.
Operational

Yes

Effective date (mm/dd/yyyy):

Managerial

Yes

Effective date (mm/dd/yyyy):

Financial

Yes

Effective date (mm/dd/yyyy):

The type(s) of control (e.g., the type and form of financial control):
Which part(s) of the SNF the control applies to:
Whether this control is furnished as a W-2 employee, under contract, or under another arrangement
Any organization listed in this attachment of which the individual is a W-2 or contracted employee:

13. Does the reported individual provide any of the following—either directly or indirectly—
to the SNF or any part of the SNF?.................................................................................................................................

Yes

If yes, complete the below fields.
Policies or procedures for any
of the SNF’s operations

Yes

Effective date (mm/dd/yyyy):

Financial services

Yes

Effective date (mm/dd/yyyy):

Cash management services

Yes

Effective date (mm/dd/yyyy):

Management services

Yes

Effective date (mm/dd/yyyy):

Administrative services

Yes

Effective date (mm/dd/yyyy):

Clinical consulting services

Yes

Effective date (mm/dd/yyyy):

Accounting services

Yes

Effective date (mm/dd/yyyy):

The type(s) of services (e.g., the type and form of financial control)
The part(s) of the SNF to which the services are furnished:
Whether these services are furnished as a W-2 employee, under contract, or under another arrangement:
Any organization listed in this attachment of which the individual is a W-2 or contracted employee:

14. Does the reported individual lease or sublease real property to the SNF?.........................................
If yes, clearly describe the type of lease arrangement and the length of the lease:

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
15. Does the reported individual directly or indirectly own at least 5 percent of the total value
of the SNF’s real property or the real property on/in which the SNF operates
(e.g., 5 percent of the real property the SNF leases)?............................................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

Whether the ownership is of real property the SNF owns or whether it is of real property the SNF leases or subleases.

16. Check the applicable box if the reported individual is the SNF’s medical director or administrator:
SNF medical director
SNF administrator
Questions 17–22 ask whether the reported individual has an ownership, trustee, or governing/managing
interest in any ADP of the SNF. Each question only applies to a particular ADP organizational type. (For
instance, question 17 only applies to interests in ADPs that are corporations, question 18 only applies to
interests in ADPs that are LLCs, etc.) These questions must be completed for all individuals reported in
section A of this Attachment, regardless of whether the individual himself/herself is an ADP. Note that if the
SNF checked “Yes” in question 10, 11, 12, 13, 14, and/or 15 (or checked one of the boxes in question 16) for a
particular reported individual, that individual is considered an ADP.
17. ADPs that are a corporation
Does the reported individual have a 5 percent or greater direct or indirect ownership interest
in any ADP of the SNF that is a corporation?.............................................................................................................
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of ownership:
Direct Indirect

Yes

Exact percentage of ownership
%

List the corporation ADP(s) of which the individual is an owner (e.g., name of the ADP)

18. ADPs that are LLCs
Does the reported individual have any direct or indirect ownership interest in any ADP
of the SNF that is an LLC, regardless of the percentage?.....................................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of ownership:
Direct Indirect

Exact percentage of ownership
%

List the LLC ADP(s) of which the individual is an owner (e.g., name of the ADP)

19. ADPs that are general partnerships
Does the reported individual have any general partnership/ownership interest in any ADP
of the SNF regardless of the percentage?....................................................................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Exact percentage of ownership
%

List the ADP(s) of which the individual is a general partner (e.g., name of the ADP)

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
20. ADPs that are limited partnerships
Does the reported individual have any general partnership interest (regardless of the percentage)
in any limited partnership ADP of the SNF or at least a 10 percent limited partnership interest in any
ADP of the SNF?....................................................................................................................................... Yes
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of partnership interest:
General Limited

Exact percentage of partnership interest
%

List the limited partnership ADP(s) of which the individual is a general or limited partner (e.g., name of the ADP)

21. ADPs that are trusts
Is the reported individual a trustee of any ADP of the SNF?..............................................................................

Yes

If yes, complete the below fields.
Effective date (mm/dd/yyyy)
List the ADP(s) of which the individual is a trustee (e.g., name of the ADP)

22. Governing/Managing/Other Individuals
Is the reported individual a corporate officer, corporate director, or LLC manager of any ADP
of the SNF? .................................................................................................................................................................................
If yes, complete the below fields.
Effective date (mm/dd/yyyy)

Type of position:
Corporate officer

Corporate director

LLC manager

Title
List the ADP(s) which the individual is a corporate officer, corporate director, or LLC manager.

23. Owners/Trustees of ADP(s)
Answer this question only if the SNF answered “Yes” to question 17, 18, 19, 20, 21, or 22. For purposes of
question 23 ONLY, the term “interest” means any of the interests (ownership, trustee, LLC managerial) listed
in the “organizational structure” definition in section 1124(c)(5)(D) of the Social Security Act. (Go to the
instructions for this definition.)
Does this ADP owner/trustee/director, etc. (as indicated in question 17, 18, 19, 20, 21, or 22)
have any interest in the SNF itself OR in another ADP of the SNF?.................................................................

Yes

If yes, complete the below field.
List the LBN of the entity (i.e., the SNF itself or another ADP of the SNF) in which this ADP owner/trustee/LLC manager has an interest.

CMS-855A: Attachment 1 (XX/XX)

ATTACHMENT 1: SKILLED NURSING FACILITY DISCLOSURES (Continued)
C. FINAL ADVERSE LEGAL ACTION
Complete this section for the individual you reported in section A. For more information on what to report,
go to section 3 of this application. Include all supporting documentation described in section 3.
If you are changing information, check “change” box, furnish the effective date, and complete the
appropriate fields in this section.
Change Effective date (mm/dd/yyyy):
1. Has the individual in section A, under any current or former name or business identity, ever had a final
adverse action listed in section 3 of this application imposed against them?
YES – continue to item 2.
NO
2. Report each final adverse legal action, when it occurred, and the federal or state agency or the court or
administrative body that imposed the action.

FINAL ADVERSE LEGAL ACTION

DATE

ACTION TAKEN BY

To satisfy the reporting requirement, fill out this section and include all applicable attachments.

CMS-855A: Attachment 1 (XX/XX)

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

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information requested on this
form by sections 1124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42
U.S.C. section 1320a-3(a)(1), 1320a-7, 1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt
Collection Improvement Act [31 U.S.C. section 7701(c)].
The purpose of collecting this information is to determine or verify the eligibility of individuals and
organizations to enroll in the Medicare program as suppliers of goods and services to Medicare beneficiaries
and to assist in the administration of the Medicare program. This information will also be used to ensure that
no payments will be made to providers who are excluded from participation in the Medicare program. All
information on this form is required, with the exception of those sections marked as “optional” on the form.
Without this information, the ability to make payments will be delayed or denied.
The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
The information in this application will be disclosed according to the routine uses described below.
Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or
abuse;
2. A congressional office from the record of an individual health care provider in response to an inquiry
from the congressional office at the written request of that individual health care practitioner;
3. The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security
Acts;
4. Peer review organizations in connection with the review of claims, or in connection with studies or other
review activities, conducted pursuant to Part B of Title XVIII of the Social Security Act;
5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the
United States Government is a party to litigation and the use of the information is compatible with the
purpose for which the agency collected the information;
6. To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to
which criminal penalties are attached;
7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors
when the National Plan and Provider System is unable to establish identity after matching contractor
submitted data to the data extract provided by the AMA;
8. An individual or organization for a research, evaluation, or epidemiological project related to the
prevention of disease or disability, or to the restoration or maintenance of health;
9. Other federal agencies that administer a federal health care benefit program to enumerate/enroll
providers of medical services or to detect fraud or abuse;
10. State Licensing Boards for review of unethical practices or non-professional conduct;
11. States for the purpose of administration of health care programs; and/or
12. Insurance companies, self-insurers, health maintenance organizations, multiple employer trusts, and
other health care groups providing health care claims processing, when a link to Medicare or Medicaid
claims is established, and data are used solely to process supplier’s health care claims.
The applicant should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503)
amended the Privacy Act, 5 U.S.C. section 552a, to permit the government to verify information through
computer matching.

Protection of proprietary information
Privileged or confidential commercial or financial information collected in this form is protected from public
disclosure by Federal law 5 U.S.C. section 552(b)(4) and Executive Order 12600.
Protection of Confidential commercial and/or sensitive personal information
If any information within this application (or attachments thereto) constitutes a trade secret or privileged
or confidential information (as such terms are interpreted under the Freedom of Information Act and
applicable case law), or is of a highly sensitive personal nature such that disclosure would constitute a clearly
unwarranted invasion of the personal privacy of one or more persons, then such information will be protected
from release by CMS under 5 U.S.C. section 552(b)(4) and/or (b)(6), respectively.

CMS-855A (XX/XX)

File Type	application/pdf
File Title	CMS-855A Medicare Enrollment Application Institutional Providers.
Subject	CMS-855A, Medicare Enrollment Application Institutional Providers
Author	Centers for Medicare and Medicaid Services
File Modified	2024-08-01
File Created	2024-06-17