Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 33
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54SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
B. Managing Control: Identifying Information (Continued)
Operational/Managerial Control
Effective Date of the operational/managerial control (mm/dd/yyyy)
Exact percentage of operational/managerial control this organization has in the provider
If this operational/managerial organization also provides contracted services to the provider, describe the types of
services furnished (e.g., managerial, billing, consultative, medical personnel staffing).
Other ownership or control/interest (please specify): ______________________________________
Effective Date of other ownership or control/interest (mm/dd/yyyy)
Exact percentage of ownership or control/interest 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).
C. Final Adverse Legal Action History
If reporting a change to existing information, check “Change,” provide the effective date of the change,
and complete the appropriate fields in this section.
Change
Effective Date:__________________________
1. Has this organization in Section 5A, under any current or former name or business identity, ever had
a final
adverse legal action listed on page 16 of this application imposed against it?
YES–Continue Below
NO–Skip to Section D
2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse legal action documentation and resolution.
FINAL ADVERSE LEGAL ACTION
DATE
TAkEN BY
RESOLUTION
CMS-855A (07/11)
32
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