Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 22

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SeCtion 5: ownerShiP intereSt and/or Managing Control inforMa tion
(organiZationS)
note: only report organizations in this section. individuals must be reported in Section 6.
Complete this section with information about all organizations that have 5 percent or more (direct
or indirect) ownership interest of, any partnership interest in, and/or managing control of, the supplier
identified in Section 2, as well as information on any adverse legal actions that have been imposed against
that organization. For examples of organizations that should be reported here, visit our Web site:
If there is more than one organization that should be
reported, copy and complete this section for each.
Managing Control (organiZationS)
Any organization that exercises operational or managerial control over the supplier, or conducts the
day-to-day operations of the supplier, is a managing organization and must be reported. The organization
need not have an ownership interest in the supplier in order to qualify as a managing organization. For
instance, it could be a management services organization under contract with the supplier to furnish
management services for the business.
SPeCial tyPeS of organiZationS
governmental/tribal organizations
If a Federal, State, county, city or other level of government, or an Indian tribe, will be legally and
financially responsible for Medicare payments received (including any potential overpayments), the name
of that government or Indian tribe should be reported as an owner. The supplier must submit a letter on the
letterhead of the responsible government (e.g., government agency) or tribal organization that attests that
the government or tribal organization will be legally and financially responsible in the event that there is
any outstanding debt owed to CMS. This letter must be signed by an appointed or elected official of the
government or tribal organization who has the authority to legally and financially bind the government or
tribal organization to the laws, regulations, and program instructions of the Medicare program.
non-Profit, Charitable and religious organizations
Many non-profit organizations are charitable or religious in nature, and are operated and/or managed by
a board of trustees or other governing body. The actual name of the board of trustees or other governing
body should be reported in this section. While the organization should be listed in Section 5, individual
board members should be listed in Section 6. Each non-profit organization should submit a copy of a
501(c)(3) document verifying its non-profit status.
CMS-855B (07/11)
21

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