Form Cms-8550 - Medicare Enrollment Application (Page 5 of 10) in pdf

SECTION 3: FINAL ADVERSE LEGAL ACTIONS

This section captures information regarding final adverse legal actions, such as convictions, exclusions,

revocations and suspensions. All applicable final adverse legal actions must be reported, regardless of whether

any records were expunged or any appeals are pending.

A. CONVICTIONS

1. Any federal or state felony convictions (as defined in 42 C.F.R. section 1001.2) within the preceding

10 years.

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.

B. 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 past or current Medicare payment suspension under any Medicare and/or Medicaid billing number.

5. Any Medicare and/or Medicaid revocation of any Medicare and/or Medicaid billing numbers.

C. FINAL ADVERSE LEGAL ACTION HISTORY

If you are reporting a change in this section, check the box below and furnish the effective date.

Change

Effective Date (mm/dd/yyyy):

1. Have you, under any current or former name, ever had a final adverse legal action listed above imposed

against you?

YES–Continue Below

NO–Skip to Section 4

2. If yes, report each final adverse legal 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 relevant final legal adverse action documents.

FINAL ADVERSE LEGAL ACTION

DATE

TAKEN BY

RESOLUTION

CMS-855O (01/17)

Form Cms-8550 - Medicare Enrollment Application Page 5