Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 33

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SeCtion 15: CertifiCation StateMent
(Continued)
B. 1
authorized official Signature
St
I have read the contents of this application. My signature legally and financially binds this supplier to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete and I authorize the Medicare fee-for-service
contractor to verify this information. If I become aware that any information in this application is not true,
correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance
with the time frames established in 42 CFR § 424.516.
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)
authorized official’s information and Signature
First Name
Middle
Last Name
Suffix (e.g., Jr., Sr.)
Initial
Telephone Number
Title/Position
Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Date Signed (mm/dd/yyyy)
(blue ink preferred)
C. 2
authorized official Signature
nd
I have read the contents of this application. My signature legally and financially binds this supplier to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete and I authorize the Medicare fee-for-service
contractor to verify this information. If I become aware that any information in this application is not true,
correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance
with the time frames established in 42 CFR § 424.516.
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)
authorized official’s information and Signature
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Telephone Number
Title/Position
Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Date Signed (mm/dd/yyyy)
all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed not original
will not be processed. Stamped, faxed or copied signatures will not be accepted.
CMS-855B (07/11)
32

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