Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 41

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SECTION 7: CHAIN HOME OFFICE INFORMATION
(Continued)
C. Chain Home Office Information
1. Name of Home Office as Reported to the Internal Revenue Service
2. Home Office Business Street Address Line 1 (Street Name and Number)
Home Office Business Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
3. Home Office Tax Identification Number
Home Office Cost Report Year-End Date (mm/dd)
4. Home Office Fee-For-Service Contractor
Home Office Chain Number
D. Type of Business Structure of the Chain Home Office
Check one:
Government:
Voluntary:
Federal
Non-Profit – Religious Organization
State
Non-Profit – Other
(Specify)
:________________
City
County
Proprietary:
City-County
Individual
Corporation
Hospital District
Partnership
Other
(Specify)
: _________________________
Other
(Specify)
: __________________________
E. Provider’s Affiliation to the Chain Home Office
Check one:
Joint Venture/Partnership
Managed/Related
Leased
Operated/Related
Wholly Owned
Other
(Specify)
: ___________________
CMS-855A (07/11)
40

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