Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 44

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SECTION 12: SPECIAL REQUIREMENTS FOR HOME HEALTH AGENCIES (HHAS)
(Continued)
4. ADDITIONAL INFORMATION
Provide any additional documentation necessary to assist the fee-for-service contractor or State agency
in properly comparing this HHA with other comparable HHAs. Use this space to explain or justify any
unique financial situations of this HHA that may be helpful in determining the HHA’s compliance with the
capitalization requirements.
B. Nursing Registries
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)
Does this HHA contract with a nursing registry whereby the latter furnishes personnel to perform HHA
services on behalf of the provider?
YES–Furnish the information below
NO–Skip to Section 13
Legal Business/Individual Name as Reported to the Internal Revenue Service
Tax Identification Number (required)
“Doing Business As” Name (if applicable)
Billing Street Address Line 1 (Street Name and Number)
Billing Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
CMS-855A (07/11)
43

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