Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 48

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SECTION 15: CERTIFICATION STATEMENT
An
means an appointed official (for example, chief executive officer, chief
AUTHORIZED OFFICIAL
financial officer, general partner, chairman of the board, or direct owner) to whom the organization
has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the
organization’s status in the Medicare program, and to commit the organization to fully abide by the
statutes, regulations, and program instructions of the Medicare program.
A
means an individual who is delegated by an authorized official the authority to
DELEGATED OFFICIAL
report changes and updates to the provider’s enrollment record. A delegated official must be an individual
with an “ownership or control interest in” (as that term is defined in Section 1124(a)(3) of the Social
Security Act), or be a W-2 managing employee of, the provider.
Delegated officials may not delegate their authority to any other individual. Only an authorized official
may delegate the authority to make changes and/or updates to the provider’s Medicare status. Even when
delegated officials are reported in this application, an authorized official retains the authority to make
any such changes and/or updates by providing his or her printed name, signature, and date of signature as
required in Section 15B.
Authorized officials and delegated officials must be reported in Section 6, either on this
NOTE:
application or on a previous application to this same Medicare fee-for-service contractor. If this is the
first time an authorized and/or delegated official has been reported on the CMS-855A, you must
complete Section 6 for that individual.
By his/her signature(s), an authorized official binds the provider to all of the requirements listed in the
Certification Statement and acknowledges that the provider may be denied entry to or revoked from the
Medicare program if any requirements are not met. All signatures must be original and in ink. Faxed,
photocopied, or stamped signatures will not be accepted.
Only an authorized official has the authority to sign (1) the initial enrollment application on behalf of
the provider or (2) the enrollment application that must be submitted as part of the periodic revalidation
process. A delegated official does not have this authority.
By signing this application, an authorized official agrees to immediately notify the Medicare fee-for-
service contractor if any information furnished on this application is not true, correct, or complete.
In addition, an authorized official, by his/her signature, agrees to notify the Medicare fee-for-service
contractor of any future changes to the information contained in this form, after the provider is enrolled in
Medicare, in accordance with the timeframes established in 42 C.F.R. 424.516(e).
The provider can have as many authorized officials as it wants. If the provider has more than two
authorized officials, it should copy and complete this section as needed.
Each authorized and delegated official must have and disclose his/her social security number.
CMS-855A (07/11)
47

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