Supplemental Facility-Based/Fiscal Year Request Statement Instructions

It is recommended this form be completed whenever a provider is submitting an 855 Enrollment Form as this form contains information that is necessary for the Contractor to properly establish the provider in the payment system to assist in ensuring prompt processing and payment of claims.

Facility-Based or Free-Standing Designation

  • The provider should check either the space next to the free-standing election (1) or the facility-based election (2).
  • Complete the Main Provider information (if electing to be a facility-based entity).
  • Complete the Facility/Organization information if electing either the free-standing election or the facility-based election.
  • The facility-based election should not be confused with the provider-based attestations as required in 42 CFR §413.65.
  • Typically, the facility-based election pertain to the following types of facilities:
    • Skilled Nursing Facilities
    • Home Health Agencies/Hospices
    • Inpatient Units excluded from IPPS (Rehabilitation and Psychiatric Units)
    • CORFs/OPTs/ESRD facilities
    • Ambulatory Surgical Centers
    • Rural Health Clinics
  • This form could also be used if a provider wishes to change their free-standing/facility-based election in the future. However, be mindful that certain providers (RHCs) that change from free-standing to facility-based may require a new Medicare Provider Number.

Fiscal Year End Request

  • The provider should identify the Fiscal Year End that they wish to establish for the free-standing election and the facility-based election.
    • If electing the facility-based option, the provider must designate the same fiscal year end as the main provider indicated on the form.
  • Do not use this form to request a change in an already established fiscal year end. Guidelines for changing an established fiscal year end can be found in the Provider Reimbursement Manual 15-1, Section 2414.3.

Authorized Personnel Information

  • The form must be signed and dated by an Officer or Administrator or authorized personnel of the provider.
  • Provide the title of the authorized personnel and contact information.
Last Updated May 04 , 2018