Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 23

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SeCtion 5: ownerShiP intereSt and/or Managing Control inforMa tion
(organiZationS)
(Continued)
All organizations that have any of the following must be reported in Section 5:
• 5 percent or more ownership of the supplier,
• Managing control of the supplier, or
• A partnership interest in the supplier, regardless of the percentage of ownership the partner has.
Owning/Managing organizations are generally one of the following types:
• Corporations (including non-profit corporations)
• Partnerships and Limited Partnerships (as indicated above)
• Limited Liability Companies
• Charitable and/or Religious organizations
• Governmental and/or Tribal organizations
a. organization with ownership interest and/or Managing Control—identification information
Not Applicable
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)
Check all that apply:
5 Percent or More Ownership Interest
Partner
Managing Control
Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
NPI (if issued)
Tax Identification Number (Required) Medicare Identification Number(s) (if issued)
What is the effective date this owner acquired ownership of the provider identified in Section 2B1 of this
application?
________________________________
(mm/dd/yyyy)
What is the effective date this organization acquired managing control of the provider identified in
Section 2B1 of this application?
________________________________
(mm/dd/yyyy)
Furnish both dates if applicable.
note:
CMS-855B (07/11)
22

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