Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 9
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54SECTION 1: BASIC INFORMATION
(Continued)
B. Check all that apply and complete the required sections:
REQUIRED SECTIONS
1, 2 (complete only those sections that are changing), 3, 13,
Identifying Information
and either 15 (if you are the authorized official) or 16 (if you
are the delegated official), and Section 6 for the signer if that
authorized or delegated official has not been established for
this provider.
1, 2B1, 3, 13, and either 15 (if you are the authorized
Adverse Legal Actions/Convictions
official) or 16 (if you are the delegated official), and Section
6 for the signer if that authorized or delegated official has not
been established for this provider.
1, 2B1, 3, 4 (complete only those sections that are
Practice Location Information,
changing), 13, and either 15 (if you are the authorized
Payment Address & Medical Record
official) or 16 (if you are the delegated official), and Section
Storage Information
6 for the signer if that authorized or delegated official has
not been established for this provider.
1, 2B1, 3, 5, 13, and either 15 (if you are the authorized
Ownership Interest and/or Managing
official) or 16 (if you are the delegated official), and Section
Control Information (Organizations)
6 for the signer if that authorized or delegated official has not
been established for this provider.
1, 2B1, 3, 6, 13, and either 15 (if you are the authorized
Ownership Interest and/or Managing
official) or 16 (if you are the delegated official), and Section
Control Information (Individuals)
6 for the signer if that authorized or delegated official has not
been established for this provider.
1, 2B1, 3, 7, 13, and either 15 (if you are the authorized
Chain Home Office Information
official) or 16 (if you are the delegated official), and Section
6 for the signer if that authorized or delegated official has not
been established for this provider.
1, 2B1, 3, 8 (complete only those sections that are
Billing Agency Information
changing), 13, and either 15 (if you are the authorized
official) or 16 (if you are the delegated official), and Section
6 for the signer if that authorized or delegated official has not
been established for this provider.
1, 2B1, 3, 12, 13, and either 15 (if you are the authorized
Special Requirements for Home
official) or 16 (if you are the delegated official), and
Health Agencies
Section 6 for the signer if that authorized or delegated
official has not been established for this provider.
1, 2B1, 3, 6, 13, and 15.
Authorized Official(s)
Delegated Official(s) (Optional)
1, 2B1, 3, 6, 13, 15, and 16.
CMS-855A (07/11)
8
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