Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 52

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SECTION 16: DELEGATED OFFICIAL(S)
(Optional) (Continued)
B. 2
Delegated Official Signature
ND
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)
51

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