Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 15

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SECTION 2: IDENTIFYING INFORMATION
(Continued)
2. ACQUIRING PROVIDER
This section is to be completed with information about the organization acquiring the provider identified in
Section 2G1.
Legal Business Name of the “Acquiring Provider” as Reported to the
Medicare Identification Number (if issued)
Internal Revenue Service
Current Fee-for-Service Contractor
National Provider Identifier
Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.
H. Consolidations
The newly formed provider completes the entire application. The providers that are being
consolidated are reported below.
1. 1
CONSOLIDATING PROVIDER
ST
This section is to be completed with information about the 1st currently enrolled provider that, as a result
of this consolidation, will no longer retain its current Medicare Identification Number.
Legal Business Name of the “Provider Being Acquired” as reported to the Internal Revenue Service
Current Fee-for-Service Contractor
Effective Date of Consolidation
Provide the name and Medicare identification number of all units of the above provider that have separate
Medicare identification numbers but have not entered into separate provider agreements, such as swing-
bed units of a hospital and HHA branches. Also furnish the NPI. Units that already have a separate
provider agreement should not be reported here.
MEDICARE IDENTIFICATION
NATIONAL PROVIDER
NAME/DEPARTMENT
NUMBER (IF ISSUED)
IDENTIFIER
2. 2
CONSOLIDATING PROVIDER
ND
This section is to be completed with information about the 2nd currently enrolled provider that, as a result
of this consolidation, will also no longer retain its current Medicare Identification Number.
Legal Business Name of the “Provider Being Acquired” as reported to the Internal Revenue Service
Current Fee-for-Service Contractor
CMS-855A (07/11)
14

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