Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 11

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SECTION 2: IDENTIFYING INFORMATION
(Continued)
A. Type of Provider
The provider must meet all Federal and State requirements for the type of provider checked. Check
only one provider type. If the provider functions as two or more provider types, a separate enrollment
application (CMS-855A) must be submitted for each type.
1. Type of Provider (other than Hospitals— See 2A2). Check only one:
Community Mental Health Center
Comprehensive Outpatient Rehabilitation Facility
Critical Access Hospital
End-Stage Renal Disease Facility
Federally Qualified Health Center
Histocompatibility Laboratory
Home Health Agency
Home Health Agency (Sub-unit)
Hospice
Indian Health Services Facility
Organ Procurement Organization
Outpatient Physical Therapy/Occupational Therapy/ Speech Pathology Services
Religious Non-Medical Health Care Institution
Rural Health Clinic
Skilled Nursing Facility
Other (Specify):_______________________
2. If this provider is a hospital, check all applicable subgroups and units listed below
and complete Section 2A3.
Hospital—General
Hospital—Acute Care
Hospital—Children’s (excluded from PPS)
Hospital—Long-Term (excluded from PPS)
Hospital—Psychiatric (excluded from PPS)
Hospital—Rehabilitation (excluded from PPS)
Hospital—Short-Term (General and Specialty)
Hospital—Swing-Bed approved
Hospital—Psychiatric Unit
Hospital—Rehabilitation Unit
Hospital—Specialty Hospital (cardiac, orthopedic, or surgical)
Other (Specify):_________________________
3. If hospital was checked in Section 2A1 or 2A2, does this hospital have a compliance plan that
states that the hospital checks all managing employees against the exclusion/debarment lists of
both the HHS Office of the Inspector General (OIG) and the General Services Administration (GSA)?
YES
NO
4. Is the provider a physician-owned hospital (as defined in the Special Enrollment Notes on
page 9)?
YES
NO
CMS-855A (07/11)
10

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