Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 26

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SeCtion 6: ownerShiP intereSt and/or Managing Control inforMation
(indiVidualS)
(Continued)
a. individuals with ownership interest and/or Managing Control—identification information
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)
The name, date of birth, and social security number of each person listed in this Section must coincide with
the individual’s information as listed with the Social Security Administration.
First Name
Middle Initial Last Name
Jr., Sr., etc. Title
Date of Birth (mm/dd/yyyy)
Place of Birth (State)
Country of Birth
Social Security Number (Required) Medicare Identification Number (if issued) NPI (if issued)
What is the above individual’s relationship with the supplier in Section 2B1? (Check all that apply.)
5 Percent or Greater Direct/Indirect Owner
Director/Officer
Authorized Official
Contracted Managing Employee
Delegated Official
Managing Employee (W-2)
Partner
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 individual 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)
25

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