SECTION 1 - BASIC INFORMATION |
- Reason for Submittal - Revalidation
- Medicare Identification Number (PTAN)
- National Provider Identifier (NPI)
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| SECTION 2 - IDENTIFYING INFORMATION |
- Type of Provider
- Supplier Identification Information
In NPI database: Sign into NPPES at https://nppes.cms.hhs.gov/NPPES/LoginPage.do?userType=PROVIDER with username and password established for your Type 2-Organizational NPI and correct Legal Business Name associated with your NPI.
- Business Information
- Legal Business Name (as reported to Internal Revenue Service (IRS))
- Organizational Structure
- Tax Identification Number (TIN)
- Incorporation Date/State Where Incorporated
- Other Name (Former Legal Business Name or Doing Business as Name)
- Proprietary or Non-Profit
- What is supplier's year end cost report date?
- Is this supplier an Indian Health Facility?
- State License Information/Certification Information
- State License Information
- Certification Information
- Correspondence Address
- Accreditation
- Name of Accrediting Organization, Type of Accreditation, effective date and expiration date
- Comments/Special Circumstances
- Explain any unique circumstances concerning your practice location, method by which you render health care services, etc.
- Change of Ownership (CHOW) Information
- Legal Business Name of "Seller/Former Owner" as reported to IRS
- DBA of Seller/Former Owner
- Old Owner's Medicare ID (PTAN)
- Old Owner's NPI
- Effective Date of Transfer (mm/dd/yyyy)
- Name of Fee-For-Service Contractor of Seller/Former Owner
- Will new owner be accepting assignment of the current "Provider Agreement?" - Check Yes or No
- Acquisitions/Mergers - Effective date of Acquisition (mm/dd/yyyy)
- Provider Being Acquired
- Legal Business Name of Provider Being Acquired, as reported to IRS
- Current Fee-For-Service Contractor
- Provide Name and PTAN/NPI of all units of Provider listed in this section that have separate PTANS but not separate provider agreements
- Acquiring Provider
- Legal Business Name of the Acquiring Provider, as reported to IRS
- Medicare ID (PTAN)
- Current Fee-For-Service Contractor
- NPI
- Consolidations
- 1st Consolidating Provider
- Legal Business Name of Provider Being Acquired, as reported to IRS
- Current Fee-For-Service Contractor
- Effective Date of Consolidation
- Provide Name and PTAN/NPI of all units of Provider listed in this section that have separate PTANS but not separate provider agreements
- 2nd Consolidating Provider
- Legal Business Name of Provider Being Acquired, as reported to IRS
- Current Fee-For-Service Contractor
- Provide Name and PTAN/NPI of all units of Provider listed in this section that have separate PTANS but not separate provider agreements
- Newly Created Provider Identification Information
- Legal Business Name of the New Provider, as reported to IRS
- Tax Identification Number
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| SECTION 3 - ADVERSE LEGAL ACTIONS/CONVICTIONS |
Has your organization, under any current or former name or business identity, ever had any of the final adverse actions listed on page 16 of CMS 855A imposed against it?
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- If yes, complete this section in its entirety.
- Include documentation regarding each adverse legal action and its resolution.
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| SECTION 4 - PRACTICE LOCATION INFORMATION |
- Practice Location Information
- Practice Location Name (or "Doing Business as" name if different from Legal Business Name)
- Practice Location Street (Physical) Address - as listed with USPS
- Practice Location Telephone Number
- Medicare Identification Number (PTAN)
- Type-2 Organization NPI
- CLIA Number for this location
- FDA/Radiology (Mammography) Certification for this location
- Type of Practice Location (Hospitals and HHAs only)
- Where Do You Want Remittance Advices (RAs) Or Special Payments Sent?
- CMS regulations require this address (special payments address) to be one of the following:
- One of practice locations listed in 4A
- A PO Box
- A Billing Agency
- Correspondence address
- Chain Home Office address
- Where Do You Keep Patients' Medical Records?
- Base of Operations Address for Mobile or Portable Providers (must include for HHA)
- Vehicle Information
- Geographic Location for Mobile or Portable Suppliers (must include for HHA)
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| SECTION 5 - OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS) |
Copy and complete this section for all direct and indirect owners of 5% or more, partners, managing organization(s), or any entity with a relationship to Provider as described in Section 5. Also, any Chain Home Office identified in Section 7, must complete a full section 5A/B/C.
For Non-Profit 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 Board of Trustees or other governing body must be listed in section 5A of Form CMS-855 (Must be listed if under a separate EIN/Legal Business Name as provider reported in section 2 of CMS-855A).
For 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 should be reported as an owner. Governmental entities must be identified in section 5A even if they are already listed in section
- Organization with Ownership Interest and/or Managing Control - Identifying Information
- Owning or managing interest's Legal Business name as Reported to IRS
- Owning or managing interest's Physical Address
- Owning or managing interest's TIN
- Check box to indicate type of organization
- Ownership/Managing Control Information - Type of Relationship to the Provider (Required for each organization in Section 5A)
- Check each applicable relationship (ownership, security interest, partnership, operational/managerial control, etc.)Indicate the Effective date
- Exact percentage of ownership/control/interest
- Was this organization solely created to acquire/buy the provider question - mark yes or no
- List types of contracted services this organization furnishes to Provider
- Final Adverse Legal Action History (Required for each organization in Section 5A)
- Has your owning/managing control organization, under any current or former name or business identity, ever had any of final adverse actions listed on page 16 of CMS-855A imposed against it?
- If yes, complete this section in its entirety.
- Include documentation regarding each adverse legal action and its resolution.
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| SECTION 6 - OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) |
Copy and complete this section for all direct and indirect owners of 5% or more, officers, directors (board of directors/board members), Chain Office Administrator, partners, managing employees, the authorized official(s) and all delegated officials, or anyone with a related interest in the provider as indicated in Section 6. All individuals listed must furnish their full Legal Name, DOB, and SSN as it is on file with Social Security Administration (SSA). At least one individual in this section must mark that he/she has managing control of supplier.
- Individuals with Ownership Interest and/or Managing Control - Identifying Information
- Owning or managing interest's Full Legal name, as listed with SSA
- Owning or managing interest's Social Security Number (SSN)
- Owning or managing interest's Date of Birth
- Owning or managing interest's relationship(s) with supplier - mark all applicable
- Indicate the Effective date
- Exact percentage of ownership/control/interest
- Title (where applicable)
- Types of contracted services this individual furnishes to Provider
- Final Adverse Legal Action History (Required for each individual in Section 6A)
- Has owning/managing individual, under any current or former name, ever had any of the final adverse actions listed on page 16 of CMS-855A imposed against it?
- If yes, complete this section in its entirety.
- Include documentation regarding each adverse legal action and its resolution.
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| SECTION 7 - CHAIN HOME OFFICE INFORMATION |
- Type of Action this Provider is Reporting - check one and list effective date
- Chain Home Office Administrator Information (Note: this individual must also complete section 6A/B in full.)
- Full Legal name, as listed with SSA
- SSN
- Date of Birth
- Chain Home Office Information
- Name of Home Office as reported to IRS
- Home Office Street Address, City, State, Zip+4
- Home Office Phone number
- Home Office TIN
- Home Office Cost Report Year-End Date (mm/dd)
- Home Office Fee-For-Service Contractor
- Home Office Chain Number
- Type of Business Structure of the Chain Home Office - check one
- Provider's Affiliation to the Chain Home Office - check one
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| SECTION 8 - BILLING AGENCY INFORMATION |
- Billing Agent(cy) Legal Business/Individual Name as Reported to SSA or IRS
- Billing Agent's Date of Birth (if Individual)
- Billing Agent(cy) Tax ID or SSN
- Doing Business As Name (if applicable)
- Billing Agency's Address - Must be PHYSICAL ADDRESS of agency
- Billing Agency's Telephone Number
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| SECTION 12 - SPECIAL REQUIREMENTS FOR HHAS |
- Type of Home Health Agency
- Check Non-profit or Proprietary
- Projected Number of Visits - 3 and 12 months
- Financial Documentation - check Yes or No
- Additional Information Provide any additional documentation necessary to assist the fee-for-service contractor 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 HHA's compliance with capitalization requirements.
- Nursing Registries - Check Yes or No
- Legal Business Name of Nursing Registry, as reported to IRS
- Tax ID number
- DBA if applicable
- Street Address, City, State, Zip+4
- Nursing Registry Agency's Telephone number
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| SECTION 13 - CONTACT PERSON(S) |
- Copy and complete section 13 for each contact person. Enter the name, address, telephone, fax and email address of the best person(s) to answer questions regarding this application or respond to requests for additional information in a timely manner. We may only discuss this application with the individuals listed in sections 13, 15 or 16 of the application.
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| SECTION 15 - CERTIFICATION STATEMENT (Authorized Official) |
- Have NAME sign and date a new/clean certification statement to approve requested revisions before submitting corrections.
- Enter Full Legal Name, Direct Phone number and Title/Position of individual signing.
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| SECTION 16 - DELEGATED OFFICIAL(S) |
- Have NAME sign and date a new/clean certification statement to approve requested revisions before submitting corrections.
- Enter Full Legal Name and Direct Phone number of individual signing.
- Check box if Delegated is a W-2 Employee of Provider in Section 2
- If adding Delegated signer, Authorized Official from Section 15 must also sign and date to assign this Delegation. These two signatures must come together and original.
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| SECTION 17 - SUPPORTING DOCUMENTS |
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A copy of a telephone or utility bill with new practice address. This must also include business LBN or DBA |
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Copy of IRS generated documentation confirming applicant's Legal Business Name and Tax Identification Number. |
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Copy of Form 501 (c) (3) for Non-Profit Organizations |
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Copy of IRS generated documentation confirming Legal Business Name and Tax Identification Number of Entity in Section 5, 7, or 8 |
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Completed CMS 588- Electronic Funds Transfer (EFT) Agreement and a letter of verification from the bank. Complete EFT as listed below. |
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Copy of Current License/Certification from Section 2 |
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Copy of Current Accreditation information as indicated in Section 2 |
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Copy of all CLIA/FDA/Diabetes certificates. |
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Copy of all health care related permits/licenses/registrations for mobile health care services rendered inside a vehicle. |
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Copy of all documents related to any adverse legal history indicated in section 3, 5, or 6 |
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Letter of attestation for government or tribal organizations: The provider must submit a letter on the letterhead of the responsible government (e.g., government agency) or tribal organization that 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 appointed or elected 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. |
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The Name, SSN and Date of Birth provided on application will not pass verification with SSA. Contact your local Social Security office and acquire documentation supporting information provided. Processing of this application will not continue until information can be verified. |
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We were not able to verify your address. Attest to address on letterhead. This must be signed and dated by Authorized or Delegated Official. |
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FQHC Only: Full copy of HRSA Grant award for FQHC's. If practice location is not listed on HRSA, then you are also required to submit the "Form 5 Part B Service Sites" document. |
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Attach an organizational flowchart identifying all of organizations listed in Section 5 and their relationship with provider and each other |
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SNF Only: Submit a diagram/flowchart identifying organizational structures of all the applicant's owners, including those that were not required to be listed in section 5 or 6. This must be submitted in addition to diagram/flowchart required for relationships identified in Section 5. |
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Copy of Bill of Sale, Lease Agreement, and Final Sales Agreement |
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Copy of a Claim to submit – Reactivations only. Furnish a copy of a claim you would plan to submit upon reactivation of billing privileges. Alternatively, you may submit on letterhead the following information regarding a beneficiary to whom provider has furnished services and for whom it will submit a claim: (1) beneficiary name, (2) Medicare ID, (3) date of service, and (4) phone number. |
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Exhibit 177 with Legal Business Name and Physical Practice Location |
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Provider-Based Attestation Statement, if you would like to be provider-based to a Hospital |
