Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 31

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SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
B. Ownership/Managing Control Information
Identify the type of ownership and/or managing control the organization identified in Section 5.A.1. has
in the provider identified in Section 2 of this application. Check all that apply. Complete all information
for each type of ownership and/or managing control applicable.
5% or greater direct ownership interest
Effective date of 5% or greater direct ownership interest (mm/dd/yyyy)
Exact percentage of direct ownership this organization has in the provider
Was this organization solely created to acquire/buy the provider and/or the provider’s assets?
Yes
No
If this organization also provides contracted services to the provider, describe the types of services furnished
(e.g., managerial, billing, consultative, medical personnel staffing).
5% or greater indirect ownership interest
Effective date of 5% or greater indirect ownership interest (mm/dd/yyyy)
Exact percentage of indirect ownership this organization has in the provider
Was this organization solely created to acquire/buy the provider and/or the provider’s assets?
Yes
No
If this organization provides contracted services to the provider, describe the types of services furnished (e.g.,
managerial, billing, consultative, medical personnel staffing).
5% or greater mortgage interest
Effective date of 5% or greater mortgage interest (mm/dd/yyyy)
Exact percentage of mortgage interest this organization has in the provider
Was this mortgage solely created to acquire/buy the provider and/or the provider’s assets?
Yes
No
CMS-855A (07/11)
30

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