Form Cms-8550 - Medicare Enrollment Application (Page 9 of 10) in pdf

SECTION 8: CERTIFICATION STATEMENT AND SIGNATURE

As an individual practitioner, you are the only person who can sign this application. The authority to sign this

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 solely to order and certify items and services for Medicare beneficiaries, or prescribe

Part D drugs. Review these requirements carefully.

By signing the Certification Statement, you agree to adhere to all of the requirements listed herein and

acknowledge that you may be denied or revoked from enrolling in the Medicare program if any requirements

are not met.

A. 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.

Under the penalty of perjury, I, the undersigned, certify to the following:

1. I understand that if I wish to be reimbursed by Medicare for services I have performed, I must first enroll

in Medicare as an individual supplier using the CMS-855I.

2. 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 and complete, I

agree to notify my designated MAC immediately.

3. I authorize the MAC to verify the information contained herein. I agree to notify the MAC of any

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.

4. 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 and/

or administrative penalties including, but not limited to the imposition of fines, civil damages and/or

imprisonment.

5. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to

the organization listed in Section 2A 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,

42 U.S.C.

1320a-7b(b) (section 1128B(b) of the Social Security Act) and the Physician Self-Referral

section

Law (Stark Law), 42 U.S.C.

1395nn (section 1877 of the Social Security Act)).

section

6. I will not knowingly order and/or certify an item and/or service or prescribe Part D drugs that allows a

false or fraudulent claim to be presented for payment by Medicare.

7. I further certify that I am the individual practitioner who is applying for the sole purpose of ordering

and certifying items or services to Medicare beneficiaries, or prescribing Part D drugs, and I have signed

and dated this application.

B. SIGNATURE AND DATE

First Name (Print)

Middle Initial

Last Name (Print)

Jr., Sr., M.D., etc.

Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

All signatures must be original. Applications with signatures deemed not original or not dated will not be processed.

Stamped, faxed or copied signatures will not be accepted.

CMS-855O (01/17)

Form Cms-8550 - Medicare Enrollment Application Page 9

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