Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 25

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SeCtion 6: ownerShiP intereSt and/or Managing Control inforMa tion
(indiVidualS)
Only Individuals should be reported in Section 6. Organizations must be reported in Section 5. For
note:
more information on “direct” and “indirect” owners, go to
the supplier MuSt have at least one owner and/or managing employee.
The following individuals must be reported in Section 6A:
• All persons who have a 5 percent or greater direct or indirect ownership interest in the supplier;
• If (and only if) the supplier is a corporation (whether for-profit or non-profit), all officers and directors
of the supplier;
• All managing employees of the supplier;
• All individuals with a partnership interest in the supplier, regardless of the percentage of ownership the
partner has; and
• Authorized and delegated officials.
A supplier is 100 percent owned by Company C, which itself is 100 percent owned by Individual
example:
D. Assume that Company C is reported in Section 5A as an owner of the supplier. Assume further that
Individual D, as an indirect owner of the supplier, is reported in Section 6A. Based on this example, the
supplier would check the “5 percent or Greater Direct/Indirect Owner” box in Section 6A.
All partners within a partnership must be reported on this application. This applies to both
note:
“General” and “Limited” partnerships. For instance, if a limited partnership has several limited partners
and each of them only has a 1 percent interest in the supplier, each limited partner must be reported on
this application, even though each owns less than 5 percent. The 5 percent threshold primarily applies to
corporations and other organizations that are not partnerships.
If you are a non-profit charitable or religious
non-Profit, Charitable or religious organizations:
organization that has no organizational or individual owners (only board members, directors or managers),
you should submit with your application a 501(c)(3) document verifying non-profit status.
For purposes of this application, the terms “officer,” “director,” and “managing employee” are defined as
follows:
is any person whose position is listed as being that of an officer in the supplier’s “articles of
officer
incorporation” or “corporate bylaws,” or anyone who is appointed by the board of directors as an officer
in accordance with the supplier’s corporate bylaws.
is a member of the supplier’s “board of directors.” It does not necessarily include a person who
director
may have the word “director” in his/her job title (e.g., departmental director, director of operations).
Moreover, where a supplier has a governing body that does not use the term “board of directors,” the
members of that governing body will still be considered “directors.” Thus, if the supplier has a governing
body titled “board of trustees” (as opposed to “board of directors”), the individual trustees are considered
“directors” for Medicare enrollment purposes.
means a general manager, business manager, administrator, director, or other
Managing employee
individual who exercises operational or managerial control over, or who directly or indirectly conducts, the
day-to-day operations of the supplier, either under contract or through some other arrangement, regardless
of whether the individual is a W-2 employee of the supplier.
If a governmental or tribal organization will be legally and financially responsible for Medicare
note:
payments received (per the instructions for Governmental/Tribal Organizations in Section 5), the supplier
is only required to report its managing employees in Section 6. Owners, partners, officers, and directors do
not need to be reported, except those who are listed as authorized or delegated officials on this application.
Any information on final adverse actions that have been imposed against the individuals reported in
this section must be furnished. If there is more than one individual, copy and complete this section for
each individual. Owners, Authorized Officials and/or Delegated Officials must complete this section.
CMS-855B (07/11)
24

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