Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 30

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SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
Not Applicable
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECk ONE
CHANGE
ADD
DELETE
DATE
(mm/dd/yyyy)
A. Ownership/Managing Control Organization
1. IDENTIFYING INFORMATION
Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Tax Identification Number (required)
Medicare Identification Number(s) (if issued)
NPI (if issued)
2. TYPE OF ORGANIZATION
Check all that apply:
Corporation
Investment firm
Limited liability Company
Bank or other financial institution
Medical provider/supplier
Consulting firm
Management services company
For-profit
Medical staffing company
Non-profit
Other (please specify):
Holding company
_________________________
CMS-855A (07/11)
29

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