Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 36

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SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION
(INDIVIDUALS)
(Continued)
5% or greater mortgage interest
Effective Date of 5% or greater mortgage interest (mm/dd/yyyy)
Exact percentage of mortgage interest 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 security interest
Effective Date of 5% or greater greater security interest (mm/dd/yyyy)
Exact percentage of security interest 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.).
General Partnership interest
Effective Date of the general partnership interest (mm/dd/yyyy)
Exact percentage of general partnership interest this individual has in the provider
If applicable, furnish this individual’s title within the provider organization (e.g., CEO, Board member, etc.)
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.).
Limited Partnership interest
Effective Date of limited partnership interest (mm/dd/yyyy)
Exact percentage of limited partnership interest this individual has in the provider
If applicable, furnish this individual’s title within the provider organization (e.g., CEO, Board member, etc.)
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)
35

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