Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 37

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SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION
(INDIVIDUALS)
(Continued)
Officer
Effective Date of office (mm/dd/yyyy)
Exact percentage of control as an Officer 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.).
Director
Effective Date as Director (mm/dd/yyyy)
Exact percentage of control as a Director 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.).
W-2 Managing Employee
Effective Date of 5% or greater direct ownership interest (mm/dd/yyyy)
Exact percentage of management control this individual has in the provider
If applicable, furnish this manager’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)
36

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