Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 49

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SECTION 15: CERTIFICATION STATEMENT
(Continued)
A. Additional Requirements for Medicare Enrollment
These are additional requirements that the provider must meet and maintain in order to bill the Medicare
program. Read these requirements carefully. By signing, the provider is attesting to having read the
requirements and understanding them.
By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in
Section 16 agree to adhere to the following requirements stated in this Certification Statement:
1. I agree to notify the Medicare contractor of any future changes to the information contained in this
application in accordance with the time frames established in 42 C.F.R. § 424.516(e). I understand
that any change in the business structure of this provider may require the submission of a new
application.
2. I have read and understand the Penalties for Falsifying Information, as printed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information
contained in this application or contained in any communication supplying information to Medicare,
or any deliberate alteration of any text on this application form, may be punished by criminal, civil,
or administrative penalties including, but not limited to, the denial or revocation of Medicare billing
privileges, and/or the imposition of fines, civil damages, and/or imprisonment.
3. I agree to abide by the Medicare laws, regulations and program instructions that apply to this
provider. The Medicare laws, regulations, and program instructions are available through the
Medicare contractor. I understand that payment of a claim by Medicare is conditioned upon
the claim and the underlying transaction complying with such laws, regulations, and program
instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), and
on the provider’s compliance with all applicable conditions of participation in Medicare.
4. Neither this provider, nor any physician owner or investor or any other owner, partner, officer,
director, managing employee, authorized official, or delegated official thereof is currently
sanctioned, suspended, debarred, or excluded by the Medicare or State Health Care Program, e.g.,
Medicaid program, or any other Federal program, or is otherwise prohibited from supplying services
to Medicare or other Federal program beneficiaries.
5. I agree that any existing or future overpayment made to the provider by the Medicare program may
be recouped by Medicare through the withholding of future payments.
6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by
Medicare, and I will not submit claims with deliberate ignorance or reckless disregard of their truth
or falsity.
7. I authorize any national accrediting body whose standards are recognized by the Secretary
as meeting the Medicare program participation requirements, to release to any authorized
representative, employee, or agent of the Centers for Medicare & Medicaid Services (CMS), a copy
of my most recent accreditation survey, together with any information related to the survey that
CMS may require (including corrective action plans).
CMS-855A (07/11)
48

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