Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 53
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54SECTION 17: SUPPORTING DOCUMENTS
This section lists the documents that, if applicable, must be submitted with this completed enrollment
application. If you are newly enrolling, or are reactivating or revalidating your enrollment, you must
provide all applicable documents. For changes, only submit documents that are applicable to that change.
The enrolling provider may submit a notarized copy of a Certificate of Good Standing from the provider’s
State licensing/certification board or other medical associations in lieu of copies of the above-requested
documents. This certification cannot be more than 30 days old.
The fee-for-service contractor may request, at any time during the enrollment process,
documentation to support or validate information that you have reported in this application.
The Medicare fee-for-service contractor may also request documents from you, other than those
identified in this section 17, as are necessary to bill Medicare.
MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES
Required documents that can only be obtained after a State survey are not required as part of the
application submission but must be furnished within 30 days of the provider receiving them. The Medicare
fee-for–service contractor will furnish specific licensing requirements for your provider type upon request.
Licenses, certifications and registrations required by Medicare or State law.
Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to
operate a health care facility.
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business
Name (e.g., IRS CP 575) provided in Section 2.
Completed Form CMS-588, Authorization Agreement for Electronic Funds Transfer.
If a provider already receives payments electronically and is not making a change to its banking
NOTE:
information, the CMS-588 is not required.
MANDATORY FOR SELECTED PROVIDER/SUPPLIER TYPES
Copy(s) of all bills of sale or sales agreements (CHOWS, Acquisition/Mergers, and
Consolidations only).
Copy(s) of all documents that demonstrate meeting capitalization requirements (HHAs only).
MANDATORY, IF APPLICABLE
Statement in writing from the bank. If Medicare payment due a provider of services is being sent to a
bank (or similar financial institution) with whom the provider has a lending relationship (that is, any
type of loan), then the provider must provide a statement in writing from the bank (which must be in
the loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables.
Copy(s) of all adverse legal action documentation (e.g., notifications, resolutions, and
reinstatement letters).
Copy of an attestation for government entities and tribal organizations
Copy of HRSA Notice of Grant Award if that is a qualifying document for FQHC status
Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit
Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically
classified as a Disregarded Entity. (e.g., Form 8832).
A disregarded entity is an eligible entity that is treated as an entity not separate from its single
NOTE:
owner for income tax purposes.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete
this information collection is estimated at 6 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.
CMS-855A (07/11)
52
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