Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 35

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SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION
(INDIVIDUALS)
(Continued)
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. Identifying Information
First Name
Middle Initial Last Name
Jr., Sr., etc.
Medicare Identification Number (if issued)
NPI (if issued)
Social Security Number (Required)
Date of Birth (mm/dd/yyyy)
Place of Birth (State)
Country of Birth
Identify the type of ownership and/or managing control the individual identified above 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 individual has in the provider
If this individual also provides contracted services to the provider, describe the types of services furnished
(e.g., managerial, billing, consultative, medical personnel staffing, etc.).
5% or greater indirect ownership interest
Effective Date of 5% or greater indirect ownership interest (mm/dd/yyyy)
Exact percentage of indirect ownership this individual has in the provider
If this individual also provides contracted services to the provider, describe the types of services furnished
(e.g., managerial, billing, consultative, medical personnel staffing, etc.).
CMS-855A (07/11)
34

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