Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 17

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SECTION 3: FINAL ADVERSE LEGAL ACTIONS/CONVICTIONS
This section captures information on 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.
Convictions
1. The provider, supplier, or any owner of the provider or supplier was, within the last 10 years preceding
enrollment or revalidation of enrollment, convicted of a Federal or State felony offense that CMS has
determined to be detrimental to the best interests of the program and its beneficiaries. Offenses include:
Felony crimes against persons and other similar crimes for which the individual was convicted,
including guilty pleas and adjudicated pre-trial diversions; financial crimes, such as extortion,
embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual
was convicted, including guilty pleas and adjudicated pre-trial diversions; any felony that placed the
Medicare program or its beneficiaries at immediate risk (such as a malpractice suit that results in
a conviction of criminal neglect or misconduct); and any felonies that would result in a mandatory
exclusion under Section 1128(a) of the Act.
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.
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 current Medicare payment suspension under any Medicare billing number.
5. Any Medicare revocation of any Medicare billing number.
CMS-855A (07/11)
16

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