Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 38

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SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION
(INDIVIDUALS)
(Continued)
Contracted Managing Employee
Effective Date of contract for managing employee (mm/dd/yyyy)
Exact percentage of this contracted managing employee’s control 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.).
Operational/Managerial Control
Effective Date of the operational/managerial control (mm/dd/yyyy)
Exact percentage of operational/managerial control 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.).
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 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)
37

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