Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 32
Download a blank fillable Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49SeCtion 15: CertifiCation StateMent
(Continued)
a. additional requirements for Medicare enrollment
These are additional requirements that the supplier must meet and maintain in order to bill the Medicare
program. Read these requirements carefully. By signing, the supplier is attesting to having read the
requirements and understanding them.
By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in
Section 16 agree to adhere to the following requirements stated in this Certification Statement:
1. I authorize the Medicare contractor to verify the information contained herein. I agree to notify
the Medicare contractor of any future changes to the information contained in this application in
accordance with the timeframes established in 42 C.F.R. § 424.516. I understand that any change in
the business structure of this supplier may require the submission of a new application.
2. I have read and understand the Penalties for Falsifying Information, as printed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information
contained in this application or contained in any communication supplying information to Medicare,
or any deliberate alteration of any text on this application form, may be punished by criminal, civil,
or administrative penalties including, but not limited to, the denial or revocation of Medicare billing
privileges, and/or the imposition of fines, civil damages, and/or imprisonment.
3. I agree to abide by the Medicare laws, regulations and program instructions that apply to this
supplier. The Medicare laws, regulations, and program instructions are available through the
Medicare contractor. I understand that payment of a claim by Medicare is conditioned upon the claim
and the underlying transaction complying with such laws, regulations, and program instructions
(including, but not limited to, the Federal anti-kickback statute and the Stark law), and on the
supplier’s compliance with all applicable conditions of participation in Medicare.
4. Neither this supplier, nor any five percent or greater owner, partner, officer, director, managing
employee, authorized official, or delegated official thereof is currently sanctioned, suspended,
debarred, or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or
any other Federal program, or is otherwise prohibited from supplying services to Medicare or other
Federal program beneficiaries.
5. I agree that any existing or future overpayment made to the supplier by the Medicare program may
be recouped by Medicare through the withholding of future payments.
6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by
Medicare, and I will not submit claims with deliberate ignorance or reckless disregard of their truth
or falsity.
7. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting
the Medicare program participation requirements, to release to any authorized representative,
employee, or agent of the Centers for Medicare & Medicaid Services (CMS) a copy of my most
recent accreditation survey, together with any information related to the survey that CMS may
require (including corrective action plans).
CMS-855B (07/11)
31
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers
Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners
Medical
Related Categories
Parent category: Medical