Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 40

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SECTION 7: CHAIN HOME OFFICE INFORMATION
This section captures information regarding chain organizations. This information will be used to ensure
proper reimbursement when the provider’s year-end cost report is filed with the Medicare fee-for-service
contractor.
For more information on chain organizations, see 42 C.F.R. 421.404.
Check here
if this section does not apply and skip to Section 8.
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. Type of Action this Provider is Reporting
CHECk ONE:
EFFECTIVE DATE
SECTIONS TO COMPLETE
Provider in chain is enrolling in Medicare for the
Complete all of Section 7.
first time
(Initial Enrollment or Change of Ownership)
.
Complete Section 7 identifying
Provider is no longer associated with the chain
the former chain home office.
Complete Section 7 in full
Provider has changed from one chain to another.
to identify the new chain
home office.
The name of provider’s chain home office is
Complete Section 7C.
changing
(all other information remains the same)
.
B. Chain Home Office Administrator Information
First Name of Home Office Administrator or CEO
Middle Initial
Last Name
Jr., Sr., etc.
Title of Home Office Administrator
Social Security Number
Date of Birth (mm/dd/yyyy)
B. CHAIN HOME OFFICE ADMINISTRATOR INFORMATION
CMS-855A (07/11)
39

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