Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 12

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SECTION 2: IDENTIFYING INFORMATION
(Continued)
B. Identification Information
1. BUSINESS INFORMATION
Legal Business Name (not the “Doing Business As” name) as reported to the Internal Revenue Service
Identify the type of organizational structure of this provider/supplier (Check one)
Corporation
Limited Liability Company
Partnership
Sole Proprietor
Other (Specify):
________________________________
Tax Identification Number
Incorporation Date (mm/dd/yyyy) (if applicable)
State Where Incorporated (if applicable)
Other Name
Type of Other Name
Former Legal Business Name
Doing Business As Name
Other (Specify):
_______________________________
Identify how your business is registered with the IRS. (
If your business is a Federal and/or State
NOTE:
government provider or supplier indicate “Non-Profit” below):
Proprietary
Non-Profit
If a checkbox indicating Proprietaryship or non-profit status is not completed, the provider/
NOTE:
supplier will be defaulted to “Proprietary.”
What is the supplier’s year end cost report date? (mm/dd/yyyy)
Is this supplier an Indian Health Facility enrolling with the designated Indian Health Service (IHS) Medicare Administrative
Contractor (MAC)?
Yes
No
CMS-855A (07/11)
11

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