Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 50
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54SECTION 15: CERTIFICATION STATEMENT
(Continued)
B. 1
Authorized Official Signature
ST
I have read the contents of this application. My signature legally and financially binds this provider to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete, and I authorize the Medicare fee-for-service
contractor to verify this information. If I become aware that any information in this application is not true,
correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance
with the time frames established in 42 C.F.R. § 424.516(e).
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)
Authorized Official’s Information and Signature
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Telephone Number
Title/Position
Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Date Signed (mm/dd/yyyy)
C. 2
Authorized Official Signature
ND
I have read the contents of this application. My signature legally and financially binds this provider to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete, and I authorize the Medicare fee-for-service
contractor to verify this information. If I become aware that any information in this application is not true,
correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance
with the time frames established in 42 C.F.R. § 424.516(e).
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)
Authorized Official’s Information and Signature
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Telephone Number
Title/Position
Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Date Signed (mm/dd/yyyy)
All signatures must be original and signed in ink. Applications with signatures deemed not original will not
be processed. Stamped, faxed or copied signatures will not be accepted.
CMS-855A (07/11)
49
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