MEdiCarE EnrollMEnt aPPliCation PhySiCianS and non-PhySiCian PraCtitionErS CMS-855i SEE PagE 1 to dEtErMinE if you arE CoMPlEting thE CorrECt aPPliCation. SEE PagE 2 for inforMation on whErE to Mail thiS aPPliCation. SEE PagE 27 to find thE liSt of thE SuPPorting doCuMEntation that MuSt bE SubMittEd with thiS aPPliCation. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB NO. 0938-0685 who Should CoMPlEtE thiS aPPliCation All physicians, as well as all non-physician practitioners listed below, must complete this application to initiate the enrollment process: Anesthesiology Assistant Mass immunization roster biller Psychologist, Clinical Audiologist Nurse practitioner Psychologist billing Certified nurse midwife Occupational therapist in independently Certified registered nurse private practice Registered Dietitian or anesthetist Physical therapist in Nutrition Professional Clinical nurse specialist private practice Speech Language Pathologist Clinical social worker Physician assistant If your supplier type is not listed above, contact your designated fee-for-service contractor before you submit this application. Complete this application if you are an individual practitioner who plans to bill Medicare and you are: • An individual practitioner who will provide services in a private setting. • An individual practitioner who will provide services in a group setting. If you plan to render all of your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17 of this application. • Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-forservice contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor). • Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location). • An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner. If you provide services in a group/organization setting, you will also need to complete a separate application, the CMS-855R, to reassign your benefits to each organization. If you terminate your association with an organization, use the CMS-855R to submit that change. billing nuMbEr inforMation The NPI is the standard unique health identifier for health care providers and is assigned by the National Plan and Provider Enumeration System (NPPES). As a Medicare healthcare supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enrollment information. Applying for the NPI is a process separate from Medicare enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov. For more information about NPI enumeration, visit www.cms.hhs.gov/NationalProvIdentStand. The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN) or Medicare Legacy Number, is a generic term for any number other than the NPI that is used to identify a Medicare supplier. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 1 inStruCtionS for CoMPlEting and SubMitting thiS aPPliCation • Type or print all information so that it is legible. Do not use pencil. • Report additional information within a section by copying and completing that section for each additional entry. • Attach all required supporting documentation. • Keep a copy of your completed Medicare enrollment package for your own records. • Send the completed application with original signatures and all required documentation to your designated fee-for-service contractor. avoid dElayS in your EnrollMEnt To avoid delays in the enrollment process, you should: • Complete all required sections. • Ensure that the correspondence address shown in Section 2 is the supplier’s address. • Enter your NPI in the applicable sections. • Enter all applicable dates. • Send the completed application with all supporting documentation to your designated fee-for-service contractor. additional inforMation For additional information regarding the Medicare enrollment process, visit www.cms.hhs.gov/ MedicareProviderSupEnroll. The fee-for-service contractor may request, at any time during the enrollment process, documentation to support and validate information reported on the application. You are responsible for providing this documentation in a timely manner. The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application to read the Privacy Act Statement. Mail your aPPliCation The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative contractor) that services your State is responsible for processing your enrollment application. To locate the mailing address for your fee-for-service contractor, go to www.cms.hhs.gov/MedicareProviderSupEnroll. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 2 SECtion 1: baSiC inforMation This section captures information regarding the reason you are submitting this application. Read this section in full prior to indicating the reason for submission on page 4. nEw EnrollEES to MEdiCarE If you are: • Enrolling in the Medicare program for the first time with this particular Medicare fee-for-service contractor. • A physician assistant whose services are reimbursed through your employer would complete this application. However, he/she would not complete the CMS 855R. notE: A physician assistant should only complete Sections 1, 2, 3, 13, 15 and 17, and should report all employers in Section 2E. EnrollEd MEdiCarE SuPPliErS The following actions apply to Medicare suppliers already enrolled in the program. Enrolling with another fee-for-service contractor If you are already enrolled with a Medicare fee-for-service contractor but are establishing a practice location in another fee-for-service contractor’s jurisdiction. reactivation To reactivate your Medicare billing privileges, submit this enrollment application. In addition, you must be able to submit a valid claim and meet all current requirements for your supplier type. voluntary termination You should voluntarily terminate your Medicare enrollment if you: • Will no longer be rendering services to Medicare patients, or • Are planning to cease (or have ceased) operations. a. national Provider identifier (nPi) Change of information If you are adding, deleting, or changing information that you previously reported to Medicare. If you are already enrolled in Medicare and are not receiving Medicare payments via EFT, any change to your enrollment information will require you to submit a CMS-588 form. All future payments will then be made via EFT. Changes in your existing enrollment data must be reported to the fee-for-service contractor in accordance with 42 C.F.R. § 424.516. revalidation CMS may require you to submit or update your enrollment information. The fee-for-service contractor 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 fee-for-service contractor. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 3 SECtion 1: baSiC inforMation a. Check one box and complete the required sections. Since physician assistants do not complete Section 4, all physician assistants must furnish their Medicare Identification Number (if issued) and their NPI here: Medicare Identification Number(s):_______________________ NPI:_______________________ If you are reassigning all of your Medicare benefits per section 4B1 of this application, furnish your Medicare Identification Number (if issued) and your individual (Type 1) NPI here: Medicare Identification Number(s):_______________________ NPI:_______________________ rEaSon for aPPliCation billing nuMbEr inforMation rEQuirEd SECtionS b. Check all that apply and completeEnter required sections. the your Medicare Identification Number (if rEQuirEd SECtionS You are a new enrollee in Medicare issued) and the NPI you would Complete all sections like to link to this number in Section 4. You are enrolling with another fee-for-service contractor Enter your Medicare Identification Number (if issued) and the NPI you would like to link to this number in Section 4. Complete all sections You are reactivating your Medicare enrollment Enter your Medicare Identification Number (if issued) and the NPI you would like to link to this number in Section 4. Complete all sections Effective Date of Termination Sections 1A, 13 and 15 You are voluntarily terminating your Medicare enrollment Medicare Identification Number(s) to Terminate (if issued): National Provider Identifier (if issued): Physician Assistants must complete Sections 1A, 2F, 13 and 15 Employers terminating Physician Assistants must complete Sections 1A, 2G, 13 and 15 CMS-855I (02/08) (EF 07/09) 4 American LegalNet, Inc. www.FormsWorkFlow.com SECtion 1: baSiC inforMation You are changing your Medicare information You are revalidating your Medicare enrollment (Continued) Medicare Identification Number (if issued): Go to Section 1B NPI: Enter your Medicare Identification Number (if issued) and the NPI you would like to link to this number in Section 4. Complete all sections b. Check all that apply and complete the required sections. rEQuirEd SECtionS Identifying Information 1, 2 (complete only those sections that are changing), 3, 13 and 15 Final Adverse Actions/Convictions 1, 2A, 3, 13 and 15 Practice Location Information, Payment Address and Medical Record Storage Information 1, 2A, 3, 4 (complete only those sections that are changing), 13 and 15 Individuals Having Managing Control 1, 2A, 3, 6, 13, and 15 Billing Agency Information 1, 2A, 3, 8 (complete only those sections that are changing), 13 and 15 CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 5 SECtion 2: idEntifying inforMation a. Personal information: your name, date of birth, and social security number must coincide with the information on your social security record. 1. First Name Middle Initial Last Name Jr., Sr., M.D., D.O., etc. 2. Other Name, First Middle Initial Last Name Jr., Sr., M.D., D.O., etc. Type of Other Name Former or Maiden Name Date of Birth 3. Gender Male Professional Name (mm/dd/yyyy) Other (Describe):____________________________________ State of Birth Country of Birth 4. Social Security Number Female Medical or other Professional School (Training Institution, if non-MD) Year of Graduation (yyyy) DEA Number (if applicable) license information License Not Applicable License Number State Where Issued Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy) Certification information Certification Not Applicable Certification Number State Where Issued Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy) b. Correspondence address Provide contact information for the person shown in Section 2A above. Once enrolled, the information provided below will be used by the fee-for-service contractor if it needs to contact you directly. This address cannot be a billing agency’s address. Mailing Address Line 1 (Street Name and Number) Mailing Address Line 2 (Suite, Room, etc.) City/Town Telephone Number CMS-855I (02/08) (EF 07/09) State Fax Number (if applicable) ZIP Code + 4 E-mail Address (if applicable) American LegalNet, Inc. www.FormsWorkFlow.com 6 SECtion 2: idEntifying inforMation (Continued) C. resident/fellow Status 1. Are you currently in an approved training program as: a. A resident? b. In a fellowship program? YES YES NO NO • If NO, skip to Section 2D. • If YES to either of the above questions, provide the name and address of the facility where you are a resident or fellow on the following lines: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ YES NO 3. Do you also render services at other facilities or practice locations? IF YES, you must report these practice locations in Section 4. YES NO 4. Are the services that you render in any of the practice locations you will be reporting in Section 4 part of your requirements for graduation from a residency or fellowship program? YES NO IF YES, has the teaching hospital reported in Section 2C1 above agreed to incur all or substantially all of the costs of training in the non-hospital facility. YES NO 2. Are the services that you render at the facility shown in Section 2C1 part of your requirements for graduation from a formal residency or fellowship program? Date of Completion:____________. If your completion date is prior to the beginning date for your practice in Section 4, skip to Section 2D. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 7 SECtion 2: idEntifying inforMation (Continued) d. Medical Specialties 1. PhySiCian SPECialty Designate your primary specialty and all secondary specialty(s) below using: P=Primary S=Secondary You may select only one primary specialty. You may select multiple secondary specialties. A physician must meet all Federal and State requirements for the type of specialty(s) checked. Addiction medicine Hematology Otolaryngology Allergy/Immunology Hematology/Oncology Pain Management Anesthesiology Infectious disease Pathology Cardiac surgery Internal medicine Pediatric medicine Cardiovascular disease (Cardiology) Interventional Pain Management Peripheral vascular disease Chiropractic Interventional radiology Colorectal surgery (Proctology) Maxillofacial surgery Medical oncology Plastic and reconstructive surgery Critical care (Intensivists) Nephrology Podiatry Dermatology Neurology Preventive medicine Diagnostic radiology Neuropsychiatry Psychiatry Emergency medicine Neurosurgery Pulmonary disease Endocrinology Nuclear medicine Radiation oncology Family practice Obstetrics/Gynecology Rheumatology Gastroenterology Ophthalmology Surgical oncology General practice Optometry Thoracic surgery General surgery Oral surgery (Dentist only) Urology Geriatric medicine Orthopedic surgery Vascular surgery Gynecological oncology Osteopathic manipulative therapy Undefined physician type (Specify):__________________ Hand surgery CMS-855I (02/08) (EF 07/09) Physical medicine and rehabilitation American LegalNet, Inc. www.FormsWorkFlow.com 8 SECtion 2: idEntifying inforMation (Continued) 2. non–PhySiCian SPECialty If you are a non-physician practitioner, check the appropriate box to indicate your specialty. All non-physician practitioners must meet specific licensing, educational, and work experience requirements. If you need information concerning the specific requirements for your specialty, contact the Medicare feefor-service contractor. Check only one of the following: If you want to enroll as more than one non-physician specialty type, you must submit a separate CMS-855I application for each. Anesthesiology assistant Physical therapist in private practice Audiologist Physician assistant Certified nurse midwife Psychologist, clinical Certified registered nurse anesthetist Psychologist billing independently Clinical nurse specialist Registered dietitian or nutrition professional Clinical social worker Speech Language Pathologist Mass immunization roster biller Undefined non-physician practitioner type (Specify): Nurse practitioner Occupational therapist in private practice CMS-855I (02/08) (EF 07/09) _______________________________________ _______________________________________ _______________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 9 SECtion 2: idEntifying inforMation (Continued) E. Physician assistants: Establishing Employment arrangement(s) Employer’s Name Effective Date of Employment Employer’s Medicare Identification Number (if issued) Employer’s NPI f. Physician assistants: terminating Employment arrangement(s) Complete this section if you are a physician assistant discontinuing your employment with a practice. Employer’s Name Effective Date of Departure Employer’s Medicare Identification Number (if issued) Employer’s NPI g. Employer terminating Employment arrangement with one or More Physician assistants This section should be used by an individual who has incorporated or is a sole proprietor, and who is discontinuing their employment arrangement with a physician assistant. Physician Assistant’s Name CMS-855I (02/08) (EF 07/09) Effective Date of Departure Physician Assistant’s Medicare Identification Number (if issued) Physician Assistant’s NPI American LegalNet, Inc. www.FormsWorkFlow.com 10 SECtion 2: idEntifying inforMation (Continued) h. Clinical Psychologists YES NO 1. Do you render services of your own responsibility free from the administrative control of an employer such as a physician, institution, or agency? YES NO Do you treat your own patients? 2. YES NO Do you have the right to bill directly, and to collect and 3. retain the fee for your services? YES NO 4. Is this private practice located in an institution? YES NO YES NO YES NO Do you hold a doctoral degree in psychology? If YES, furnish the field of your psychology degree__________________________ Attach a copy of the degree with this application. i. Psychologists billing independently If YES to question 4 above, please answer questions “a” and “b” below. a) If your private practice is located in an institution, is your office confined to a separately identified part of the facility that is used solely as your office and cannot be construed as extending throughout the entire institution? b) If your private practice is located in an institution, are your services also rendered to patients from outside the institution or facility where your office is located? J. Physical therapists/occupational therapists in Private Practice (Pt/ot) The following questions only apply to your individual practice. They do not apply if you are reassigning all of your benefits to a group/organization. 1. Are all of your PT/OT services only rendered in the patients’ homes? YES NO Do you maintain private office space? 2. YES NO Do you own, lease, or rent your private office space? 3. YES NO 4. Is this private office space used exclusively for your private practice? YES NO 5. Do you provide PT/OT services outside of your office and/or patients’ homes? YES NO If you respond YES to any of the questions 2–5 above, attach a copy of the lease agreement that gives you exclusive use of the facility for PT/OT services. K. nurse Practitioners and Certified Clinical nurse Specialists Are you an employee of a Medicare skilled nursing facility (SNF) or of another entity that has an agreement to provide nursing services to a SNF? YES NO If yes, include the SNF’s name and address. Name Street Address City CMS-855I (02/08) (EF 07/09) State Zip American LegalNet, Inc. www.FormsWorkFlow.com 11 SECtion 3: final advErSE aCtionS/ConviCtionS This section captures information on final adverse actions, such as convictions, exclusions, revocations, and suspensions. All applicable final adverse actions must be reported, regardless of whether any records were expunged or any appeals are pending. Enrolled suppliers are required to report all Final Adverse Actions/Convictions within 30 days of the reportable event. final advErSE aCtionS that MuSt bE rEPortEd Convictions 1. The provider, supplier, or any owner of the provider or supplier was, within the last 10 years preceding enrollment or revalidation of enrollment, convicted of a Federal or State felony offense that CMS has determined to be detrimental to the best interests of the program and its beneficiaries. Offenses include: Felony crimes against persons and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre-trial diversions; financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre-trial diversions; any felony that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit that results in a conviction of criminal neglect or misconduct); and any felonies that would result in a mandatory exclusion under Section 1128(a) of the Social Security Act. 2. 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. 3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care item or service. 4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section 1001.101 or 1001.201. 5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. Exclusions, revocations, or Suspensions 1. Any revocation or suspension of a license to provide health care by any State licensing authority. This includes the surrender of such a license while a formal disciplinary proceeding was pending before a State licensing authority. 2. Any revocation or suspension of accreditation. 3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or State health care program, or any debarment from participation in any Federal Executive Branch procurement or non-procurement program. 4. Any current Medicare payment suspension under any Medicare billing number. 5. Any Medicare revocation of any Medicare billing number. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 12 SECtion 3: final advErSE aCtionS/ConviCtionS (Continued) final advErSE hiStory 1. Have you, under any current or former name or business identity, ever had a final adverse action listed on page 12 of this application imposed against you? YES–Continue Below NO–Skip to Section 4 2. If yes, report each final adverse action, when it occurred, the Federal or State agency or the court/administrative body that imposed the action, and the resolution, if any. Attach a copy of the final adverse action documentation and resolution. final adverse action date ___________________ ___________________ ___________________ _________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ CMS-855I (02/08) (EF 07/09) taken by resolution American LegalNet, Inc. www.FormsWorkFlow.com 13 SECtion 4: PraCtiCE loCation inforMation a. Establishing a Professional Corporation, Professional association, limited liability Company, etc. If you are the sole owner of a professional corporation, a professional association, or a limited liability company, and will bill Medicare through this business entity, complete this section 4A, skip to Section 4C, and complete the remainder of the application with information about your business entity. Legal Business Name as Reported to the Internal Revenue Service Tax Identification Number Medicare Identification Number (if issued) NPI Incorporation Date (mm/dd/yyyy) (if applicable) State Where Incorporated (if applicable) final advErSE hiStory 1. Has your organization, under any current or former name or business identity, ever had any of the final adverse actions listed on page 12 of this application imposed against it? YES–Continue Below NO–Skip to Section 4 2. If yes, report each final adverse action, when it occurred, the Federal or State agency or the court/administrative body that imposed the action, and the resolution, if any. Attach a copy of the final adverse action documentation and resolution. final adverse action date taken by resolution ___________________ ___________________ ___________________ _________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ If you are the sole owner of a professional corporation, a professional association, or a limited liability company, and will bill Medicare through this business entity, you do not need to complete a CMS-855R that reassigns your benefits to the business entity. b. individual affiliations Complete this section with information about your private practice and group affiliations. Furnish the requested information about each group/organization to which you will reassign your benefits. In addition, either you or each group/organization reported in this section must complete and submit a CMS 855R(s) (Individual Reassignment of Benefits) with this application. Reassigning benefits means that you are authorizing the group/organization to bill and receive payment from Medicare for the services you have rendered at the group/organization’s practice location. If you are an individual who is reassigning all of your benefits to a group, neither you nor the group needs to submit a CMS-588 (Electronic Funds Transfer Authorized Agreement) to facilitate that reassignment. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 14 SECtion 4: PraCtiCE loCation inforMation (Continued) 1. If you are reassigning all of your payments to another group or organization furnish the name, Medicare identification number(s) and NPI of each group or organization below and proceed to Section 13. 2. If any of your payments are part of your private practice and a group or organization furnish the name and Medicare identification number(s) and NPI of each group or organization below and continue to Section 4C (where you will enter your private practice information). 3. If you are not reassigning all or any of your payments to another group or organization, skip to Section 4C with information about your private practice. a) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier b) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier c) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier d) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier e) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier C. Practice location information • If you completed Section 4A, complete Section 4C through Section 17 for your business. • All locations disclosed on claims forms should be identified in this section as practice locations. • Complete this section for each of your practice locations where you render services to Medicare beneficiaries. However, you should only report those practice locations within the jurisdiction of the Medicare feefor-service contractor to which you will submit this application. If you render services in a hospital and/or other health care facility, furnish the name and address of that hospital or facility. • Each practice location must be a specific street address as recorded by the United States Postal Service. Do not report a P.O. Box. • If you only render services in patients’ homes (house calls), you may supply your home address in this section if you do not have an office. In Section 4H, explain that this address is for administrative purposes only and that all services are rendered in patients’ homes. • If you render services in a retirement or assisted living community, complete this section with the names, telephone numbers and addresses of those communities. If you have a CLIA number and/or FDA/Radiology Certification Number for this practice location, provide that information and submit a copy of the most current CLIA and FDA certification for each practice location reported. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 15 SECtion 4: PraCtiCE loCation inforMation (Continued) If you or your organization sees patients in more than one practice location, copy and complete this Section 4C for each location. If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) If you are enrolling for the first time, or if you are adding a new practice location, the date you provide should be the date you saw your first Medicare patient at this location. Practice Location Name (“Doing Business As” name if different from Legal Business Name) Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box) Practice Location Street Address Line 2 (Suite, Room, etc.) City/Town Telephone Number State Fax Number (if applicable) Medicare Identification Number (if issued) ZIP Code + 4 E-mail Address (if applicable) NPI Date you saw your first Medicare patient at this practice location Is this practice location a: Private practice office setting Hospital CLIA Number for this location (if applicable) CMS-855I (02/08) (EF 07/09) Retirement/assisted living community Other health care facility (Specify):___________________________________ FDA/Radiology (Mammography) Certification Number for this location (if issued) American LegalNet, Inc. www.FormsWorkFlow.com 16 SECtion 4: PraCtiCE loCation inforMation (Continued) d. rendering Services in Patients’ homes List the city/town, State, and ZIP code for all locations where health care services are rendered in patients’ homes. If you provide health care services in more than one State and those States are serviced by different Medicare fee-for-service contractors, complete a separate enrollment application (CMS-855I) for each Medicare fee-for-service contractor’s jurisdiction. If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) initial rEPorting and/or additionS If you are reporting or adding an entire State, it is not necessary to report each city/town. Simply check the box below and specify the State. Entire State of __________________________ If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are not servicing the entire city/town. City/town State ZiP Code ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ dElEtionS If you are deleting an entire State, it is not necessary to report each city/town. Simply check the box below and specify the State. Entire State of __________________________ If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are not servicing the entire city/town. City/town State ZiP Code ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 17 SECtion 4: PraCtiCE loCation inforMation (Continued) E. where do you want remittance notices or Special Payments Sent? If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT, the “Special Payments” address will indicate where all other payment information (e.g., remittance notices, special payments) are sent. “Special Payments” address is the same as the practice location (only one address is listed in Section 4C). Skip to Section 4F. “Special Payments” address is different than that listed in Section 4C, or multiple locations are listed. Provide address below. Furnish the address where remittance notices and special payments should be sent for services rendered at the practice location(s) in Section 4C. Note that payments will be made in your name; if an entity is listed in Section 4A of this application, payments will be made in the organization’s name. “Special Payment” Address Line 1 (PO Box or Street Name and Number) “Special Payment” Address Line 2 (Suite, Room, etc.) City/Town State ZIP Code + 4 f. Employer id number information notE: If you are a sole proprietor and you want Medicare payments to be reported under your EIN, list it below. Unless indicated in this section, payments will be made to your SSN. You cannot use both an SSN and EIN. You can only use one EIN to bill Medicare. To qualify for this payment arrangement, you: • Must be a sole proprietor, • Cannot reassign all of your Medicare payments, and, • Want your payments to be made to your EIN. Furnish IRS documentation showing your EIN. Employer Identification Number (EIN) CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 18 SECtion 4: PraCtiCE loCation inforMation (Continued) g. where do you Keep Patients’ Medical records? If the patients’ medical records are stored at a location other than the location shown in Section 4C, complete this section with the name and address of the storage location. This includes both current and former patients’ records. Post Office Boxes and drop boxes are not acceptable as physical addresses where patients’ records are maintained. The records must be your records, not those of another supplier. If this section is not completed, you are indicating that all records are stored at the practice locations reported in Section 4C. If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. first Medical record Storage facility (for current and former patients) ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) Storage Facility Address Line 1 (Street Name and Number) Storage Facility Address Line 2 (Suite, Room, etc.) City/Town State ZIP Code + 4 Second Medical record Storage facility (for current and former patients) ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) Storage Facility Address Line 1 (Street Name and Number) Storage Facility Address Line 2 (Suite, Room, etc.) City/Town State ZIP Code + 4 h. unique Circumstances Explain any unique circumstances concerning your practice locations or the method by which you render health care services (e.g., you only render services in patients’ homes [house calls only]). SECtion 5: for futurE uSE CMS-855I (02/08) (EF 07/09) (this Section not applicable) American LegalNet, Inc. www.FormsWorkFlow.com 19 SECtion 6: individualS having Managing Control This section captures information about all managing employees. A managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or manage­ rial control over, or who directly or indirectly conducts, the day-to-day operations of the supplier, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee of the supplier. All managing employees at any of your practice locations shown in Section 4 must be reported in this section. If there is more than one managing employee, copy and complete this section as needed. a. Managing Employee – identifying information If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) 1. First Name Middle Initial 2. Title Last Name Jr., Sr., etc. Date of Birth (mm/dd/yyyy) 3. Social Security Number (Required) Medicare Identification Number (if issued) NPI (if issued) b. final adverse history Complete this section for the individual reported in Section 6A above. If you are changing or adding information, check the “change” box, furnish the effective date, and complete the appropriate fields in this section. Change Effective Date:______________________ 1. Has this individual in Section 6A above, under any current or former name or business identity, ever had a final adverse action listed on page 12 of this application imposed against him/her? YES–Continue Below NO–Skip to Section 8 2. If yes, report each final adverse action, when it occurred, the Federal or State agency or court/administrative body that imposed the action, and the resolution, if any. final adverse action date taken by resolution ___________________ ___________________ ___________________ _________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ _______________________ ______________________ ______________________ _____________________ CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 20 SECtion 7: for futurE uSE (this Section not applicable) SECtion 8: billing agEnCy inforMation A billing agency is a company or individual that you contract with to prepare and submit your claims. If you use a billing agency, you are responsible for the claims submitted on your behalf. ChECK hErE if this section does not apply and skip to Section 13. billing agency name and address If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. ChECK onE datE CHANGE ADD DELETE (mm/dd/yyyy) Legal Business Name (as Reported to the Internal Revenue Service) Tax ID Number or Social Security Number (required) “Doing Business As” Name (if applicable) Billing Agency Address Line 1 (Street Name and Number) Billing Agency Address Line 2 (Suite, Room, etc.) City/Town Telephone Number State Fax Number (if applicable) SECtion 9: for futurE uSE ZIP Code + 4 E-mail Address (if applicable) (this Section not applicable) SECtion 10: for futurE uSE (this Section not applicable) SECtion 11: for futurE uSE (this Section not applicable) SECtion 12: for futurE uSE (this Section not applicable) CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 21 SECtion 13: ContaCt PErSon This section captures information regarding the person you would like for us to contact regarding this application. If no one is listed below, we will contact you directly. First Name Telephone Number Middle Initial Last Name Fax Number (if applicable) Jr., Sr., etc. E-mail Address (if applicable) Address Line 1 (Street Name and Number) Address Line 2 (Suite, Room, etc.) City/Town CMS-855I (02/08) (EF 07/09) State ZIP Code + 4 American LegalNet, Inc. www.FormsWorkFlow.com 22 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. 1.18 U.S.C. § 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. § 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. § 3729, imposes civil liability, in part, on any person who: a) knowingly presents, or causes to be presented, to an officer or any employee of the United States Government a false or fraudulent claim for payment or approval; b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; or c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid. The Act imposes a civil penalty of $5,000 to $10,000 per violation, 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. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 23 SECtion 14: PEnaltiES for falSifying inforMation (Continued) 6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute, or attempt, to executive 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 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-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 24 SECtion 15: CErtifiCation StatEMEnt As an individual practitioner, you are the only person who can sign this application. The authority to sign the application on your behalf may not be delegated to any other person. The Certification Statement contains certain standards that must be met for initial and continuous enrollment in the Medicare program. Review these requirements carefully. By signing the Certification Statement, you agree to adhere to all of the requirements listed therein and acknowledge that you may be denied entry to or revoked from the Medicare program if any requirements are not met. Certification Statement You MUST sign and date the certification statement below in order to be enrolled in the Medicare program. In doing so, you are attesting to meeting and maintaining the Medicare requirements stated below. I, the undersigned, certify to the following: 1. I have read the contents of this application, and the information contained herein is true, correct, and complete. If I become aware that any information in this application is not true, correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact immediately. 2. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the Medicare contractor of a change in ownership, practice location and/or Final Adverse Action within 30 days of the reportable event. In addition, I agree to notify the Medicare contractor of any other changes to the information to this form within 90 days of the effective date of change. I understand that any change to my status as an individual practitioner may require the submission of a new application. I understand that any change in business structure of this supplier may require the submission of a new application. 3. I have read and understand the Penalties for Falsifying Information, as printed in this application. I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to Medicare, or any deliberate 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. 4. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to the organization listed in Section 4A of this application. The Medicare laws, regulations, and program instructions are available through the fee-for-service 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 and the Stark law), and on the supplier’s compliance with all applicable conditions of participation in Medicare. 5. Neither I, nor any managing employee listed on this application, is currently sanctioned, suspended, debarred, or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or any other Federal program, or is otherwise prohibited from providing services to Medicare or other Federal program beneficiaries. 6. I agree that any existing or future overpayment made to me (or to the organization listed in Section 4A of this application) by the Medicare program may be recouped by Medicare through the withholding of future payments. 7. I understand that the Medicare identification number issued to me can only be used by me or by a provider or supplier to whom I have reassigned my benefits under current Medicare regulations, when billing for services rendered by me. 8. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare, and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity. 9. I further certify that I am the individual practitioner who is applying for Medicare billing privileges. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 25 SECtion 15: CErtifiCation StatEMEnt First Name Middle Initial (Continued) Last Name Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) M.D., D.O., etc. Date Signed (mm/dd/yyyy) all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted. SECtion 16: for futurE uSE CMS-855I (02/08) (EF 07/09) (this Section not applicable) American LegalNet, Inc. www.FormsWorkFlow.com 26 SECtion 17: SuPPorting doCuMEntS This section lists the documents that, if applicable, must be submitted with this enrollment application. For changes, only submit documents that are applicable to the change requested. The fee-for-service contractor may request, at any time during the enrollment process, documentation to support or validate information reported on the application. Mandatory for all ProvidEr/SuPPliEr tyPES Completed Form CMS-588, for Electronic Funds Transfer Authorization Agreement. NOTE: If a supplier already receives payments electronically and is not making a change to his/her banking information, the CMS-588 is not required. (Moreover, physicians and non-physician practitioners who are reassigning all of their payments to another entity are not required to submit the CMS-588.) Mandatory, if aPPliCablE Copy(s) of all final adverse action documentation (e.g., notifications, resolutions, and reinstatement letters). Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement. Completed Form CMS-855R, Individual Reassignment of Medicare Benefits. Statement in writing from the bank. If Medicare payment due a supplier of services is being sent to a bank (or similar financial institution) where the supplier has a lending relationship (that is, any type of loan), then the supplier 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. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated to 4 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. do not Mail aPPliCationS to thiS addrESS. Mailing your application to this address will significantly delay application processing. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 27 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEdiCarE SuPPliEr EnrollMEnt aPPliCation PrivaCy aCt StatEMEnt The Centers for Medicare and 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. §§ 1320a-3(a)(1), 1320a7, 1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt Collection Improvement Act [31 U.S.C. § 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), and the system number 09-70-0525 titled Unique Physician/Practitioner Identification Number (UPIN) System (published in Vol. 61 of the Federal Register at page 20,528 (May 7, 1996)). 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 Unique Physician Identification Number Registry 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 enrolling supplier 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. § 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. § 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. §§ 552(b)(4) and/or (b)(6), respectively. CMS-855I (02/08) (EF 07/09) American LegalNet, Inc. www.FormsWorkFlow.com 28