Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 34

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SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS)
This section is to be completed with information about any individual who has direct or indirect ownership
of, a partnership interest in, and/or managing control of the provider identified in Section 2 of this
application. If there is more than one individual, copy and complete this section for each. Note that the
provider must have at least one managing employee.
Only individuals should be reported in this section. Organizations should be reported in Section 5.
If adding, deleting, or changing information on an existing owner, partner, or managing individual, check
the appropriate box, indicate the effective date of the change, complete the appropriate fields in this
section, and sign and date the certification statement.
A. Ownership and Control
The following ownership control interests, as they are described in the instructions to Section 5, must be
reported in this section:
• 5% or greater direct ownership interest
• 5% or greater indirect ownership interest
• 5% or greater mortgage or security interest
• All general partnership interests, regardless of the percentage. This includes: (1) all interests in a non-
limited partnership, and (2) all general partnership interests in a limited partnership.
• Limited partnership interests if the individual’s interest in the partnership is at least 10%.
• Officers and Directors, if the entity is organized as a corporation.
For more information on these interests, please see Section 5. Note that the diagrams referred to in
Section 5(A)(5) of the instructions must include all individuals with any of the ownership interests
described above.
All managing employees of the provider must be reported in this section. The term “managing employee”
means a general manager, business manager, administrator, director, or other individual who exercises
operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of
the provider, either under contract or through some other arrangement, regardless of whether the individual
is a W-2 employee of the provider.
If a governmental or tribal organization will be legally and financially responsible for Medicare
NOTE:
payments received (per the instructions for Governmental/Tribal Organizations in Section 5), the provider
is only required to report its managing employees in Section 6. Owners, partners, officers and directors do
not need to be reported, except those who are listed as authorized or delegated officials on this application.
B. Adverse Legal History
This section is to be completed with any adverse legal history information about any individual owner,
partner and/or individual with managing control of the provider identified in Section 2.
CMS-855A (07/11)
33

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