Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 26
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54SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
This section is to be completed with information about any organization that has direct or indirect
ownership of, a partnership interest in, and/or managing control of the provider identified in Section 2.
If there is more than one organization, copy and complete this section for each. (See examples below of
organizations that should be reported in this section.)
Only organizations should be reported in this section. Individuals should be reported in Section 6.
If adding, deleting, or changing information on an existing owner, partner, or managing organization,
check the appropriate box, indicate the effective date of the change, complete the appropriate fields in this
section, and sign and date the certification statement.
A. Ownership
The following ownership interests must be reported in this section.
1. DIRECT OWNERSHIP INTEREST
Examples of direct ownership are as follows:
• The provider is a skilled nursing facility that is wholly (100%) owned by Company A. As such, the
provider would have to report Company A in this section.
• A hospice wants to enroll in Medicare. Company X owns 50% of the hospice. Company X would have
to be reported in this section.
In the first example, Company A is considered a direct owner of the skilled nursing facility, in that it
actually owns the assets of the business. Similarly, Company X is a direct owner of the hospice mentioned
in the second example. It has 50% actual ownership of the hospice.
2. INDIRECT OWNERSHIP INTEREST
Many organizations that directly own a provider are themselves wholly or partly owned by other
organizations (or even individuals). This is often the result of the use of holding companies and parent/
subsidiary relationships. Such organizations and individuals are considered to be “indirect” owners of the
provider. Using the first example in #1 above, if Company B owned 100% of Company A, Company B is
considered to be an indirect owner of the provider. In other words, a direct owner has an actual ownership
interest in the provider (e.g., owns stock in the business, etc.), whereas an indirect owner has an ownership
interest in an organization that owns the provider.
Consider the following example of indirect ownership:
ExAMPLE 1: OWNERSHIP
LEVEL 3
Individual x
Individual Y
5%
30%
LEVEL 2
Company C
Company B
60%
40%
LEVEL 1
Company A
100%
CMS-855A (07/11)
25
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