Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 39

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SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING
CONTROL INFORMATION
(INDIVIDUALS)
(Continued)
B. Final Adverse Legal Action History
Complete this section for the individual reported in Section 6A above.
If you are changing information, check “change” box, furnish the effective date, and complete the
appropriate fields in this section.
Change
Effective Date:__________________________
1. Has the individual in Section 6A, under any current or former name or business identity, ever had a
final adverse legal action listed on page 16 of this application imposed against him/her?
YES–Continue Below
NO–Skip to Section 7
2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse legal action documentation and resolution.
FINAL ADVERSE LEGAL ACTION
DATE
TAkEN BY
RESOLUTION
CMS-855A (07/11)
38

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