Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 32
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54SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
B. Managing Control: Identifying Information (Continued)
5% or greater security interest
Effective date of 5% or greater security interest (mm/dd/yyyy)
Exact percentage of security interest this organization has in the provider
Was this security solely created to acquire/buy the provider and/or the provider’s assets?
Yes
No
General Partnership interest
Effective Date of the general partnership interest (mm/dd/yyyy)
Exact percentage of general partnership interest this organization has in the provider
Was this general partnership solely created to acquire/buy the provider and/or the provider’s assets?
Yes
No
If this general partnership also provides contracted services to the provider, describe the types of services furnished
(e.g., managerial, billing, consultative, medical personnel staffing).
Limited Partnership interest
Effective Date of the limited partnership interest (mm/dd/yyyy)
Exact percentage of limited partnership interest this organization has in the provider
Was this limited partnership solely created to acquire/buy the provider and/or the provider’s assets?
Yes
No
If this limited partnership also provides contracted services to the provider, describe the types of services furnished
(e.g., managerial, billing, consultative, medical personnel staffing).
CMS-855A (07/11)
31
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