Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 51

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SECTION 16: DELEGATED OFFICIAL(S)
(Optional)
• You are not required to have a delegated official. However, if no delegated official is assigned, the
authorized official(s) will be the only person(s) who can make changes and/or updates to the provider’s
status in the Medicare program.
• The signature of a delegated official shall have the same force and effect as that of an authorized
official, and shall legally and financially bind the provider to the laws, regulations, and program
instructions of the Medicare program. By his or her signature, the delegated official certifies that
he or she has read the Certification Statement in Section 15 and agrees to adhere to all of the stated
requirements. The delegated official also certifies that he/she meets the definition of a delegated
official. When making changes and/or updates to the provider’s enrollment information maintained by
the Medicare program, the delegated official certifies that the information provided is true, correct, and
complete.
• Delegated officials being deleted do not have to sign or date this application.
• Independent contractors are not considered “employed” by the provider and, therefore, cannot be
delegated officials.
• The signature(s) of an authorized official in Section 16 constitutes a legal delegation of authority to any
and all delegated official(s) assigned in Section 16.
• If there are more than two individuals, copy and complete this section for each individual.
A. 1
Delegated Official Signature
ST
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)
Delegated Official First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Delegated Official Signature
Date Signed (mm/dd/yyyy)
(First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Telephone Number
Check here if Delegated Official is a W-2 Employee
Assigning this Delegation
Date Signed (mm/dd/yyyy)
Authorized Official Signature
(First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
CMS-855A (07/11)
50

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