Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 35

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SeCtion 16: delegated offiCial (oPtional)
B. 2
delegated official Signature
nd
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)
Delegated Official First Name
Middle Initial Last Name
Suffix (e.g., Jr., Sr.)
Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Date Signed (mm/dd/yyyy)
Telephone Number
Check here if Delegated Official is a W-2 Employee
Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr.,
Date Signed (mm/dd/yyyy)
M.D., D.O., etc.)
(blue ink preferred)
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)
34

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