Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 29

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SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
5. ADDITIONAL INFORMATION ON OWNERSHIP
All entities that meet any the requirements above must be reported in this section, including, but not
limited to:
• Entities with an investment interest in the provider (e.g., investment firms)
• Banks and financial institutions (e.g., mortgage interests)
• Holding companies
• Trusts and trustees
• Governmental/Tribal Organizations: If a Federal, State, county, city or other level of government, or an
Indian tribe, will be legally and financially responsible for Medicare payments received (including any
potential overpayments), the name of that government or Indian tribe must be reported as an owner. The
provider must submit a letter on the letterhead of the responsible government (e.g., government agency)
or tribal organization, which attests that the government or tribal organization will be legally and
financially responsible in the event that there is any outstanding debt owed to CMS. This letter must
be signed by an “authorized official” of the government or tribal organization who has the authority to
legally and financially bind the government or tribal organization to the laws, regulations, and program
instructions of Medicare. See Section 15 for further information on “authorized officials.”
• Charitable and Religious Organizations: Many non-profit organizations are charitable or religious in
nature, and are operated and/or managed by a Board of Trustees or other governing body. The actual
name of the Board of Trustees or other governing body should be reported in this section.
In addition to furnishing the information in this section, the provider must submit:
• An organizational diagram identifying all of the entities listed in this section and their relationships with
the provider and with each other.
• If the provider is a skilled nursing facility, a diagram identifying the organizational structures of all of
its owners, including owners that were not required to be listed in this section or in Section 6.
B. Managing Control
Any organization that exercises operational or managerial control over the provider, or conducts the day-
to-day operations of the provider, is a managing organization and must be reported. The organization need
not have an ownership interest in the provider in order to qualify as a managing organization. For instance,
it could be a management services organization under contract with the provider to furnish management
services for the business.
C. Managing Control: Adverse Legal History
This section is to be completed with any adverse legal history information about any ownership
organization, partnership and/or organization with managing control of the provider identified in Section 2.
CMS-855A (07/11)
28

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