Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 28
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54SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
3. MORTGAGE OR SECURITY INTEREST
All entities with at least a 5% mortgage, deed of trust, or other security interest in the provider must
be reported in this section. To calculate whether this interest meets the 5% threshold, use the following
formula:
• Dollar amount of the mortgage, deed of trust, or other obligation secured by the provider or any
of the property or assets of the provider
DIVIDED BY
Dollar amount of the total property and assets of the provider
Example: Two years ago, a provider obtained a $20 million loan from Entity X to add a third floor to its
facility. Various assets of the provider secure the mortgage. The total value of the provider’s property and
assets is $100 million.
Using the formula described above, divide $20 million (the dollar amount of the secured mortgage) by
$100 million (the total property and assets of the Enrolling Provider). This results in .20, or 20%. Because
Entity X’s interest represents at least 5% of the total property and assets of the Enrolling Provider, Entity
X must be reported in this section.
4. PARTNERSHIPS
All general partnership interests—regardless of the percentage—must be reported. This includes: (1) all
interests in a non-limited partnership, and (2) all general partnership interests in a limited partnership.
For limited partnerships, all limited partners must be reported if their interest in the partnership is at least
10%. To illustrate, assume a provider is a limited partnership. The general partner has a 60% interest in
the entity, while the 4 limited partners each own 10%. The general partnership must be reported in this
application. Likewise, the 4 limited partners must be reported, as they each own at least 10% of the
limited partnership.
CMS-855A (07/11)
27
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