Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 27

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SeCtion 6: ownerShiP intereSt and/or Managing Control inforMa tion
(indiVidualS)
(Continued)
B. final adverse legal action history
Complete this section for the individual reported in Section 6A above. If reporting a change to existing
information, check “change,” provide the effective date of the change and complete the appropriate fields
in this section.
Change
Effective Date:______________________
1. Has this individual in Section 6A above, under any current or former name or business identity, ever
had a final adverse legal action listed on page 13 of this application imposed against him/her?
YES–Continue Below
NO–Skip to Section 8
2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse legal action documentation and resolution.
final adVerSe legal aCtion
date
taken By
reSolution
CMS-855B (07/11)
26

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