Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 36

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SeCtion 17: SuPPorting doCuMentS
This section lists the documents that, if applicable, must be submitted with this enrollment application.
If you are newly enrolling, or are reactivating or revalidating your enrollment, you must provide all
applicable documents. For changes, only submit documents that are applicable to that change.
The fee-for-service contractor may request, at any time during the enrollment process,
documentation to support or validate information reported on the application. The Medicare fee-for-
service contractor may also request documents from you, other than those identified in this Section
17, as are necessary to bill Medicare.
Mandatory for all ProVider/SuPPlier tyPeS
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business
Name (e.g., IRS form CP 575) provided in Section 2.
(
This information is needed if the applicant is enrolling their professional corporation,
note:
professional association, or limited liability corporation with this application or enrolling as a sole
proprietor using an Employer Identification Number.)”
Completed Form CMS-588, for Electronic Funds Transfer Authorization Agreement.
(
If a supplier already receives payments electronically and is not making a change to its banking
note:
information, the CMS-588 is not required.)
Mandatory for SeleCted ProVider/SuPPlier tyPeS
Copy(s) of all documentation verifying IDTF Supervisory Physician(s) proficiency and/or State
licenses or certification for IDTF non-physician personnel.
Copy(s) of all documentation verifying the State licenses or certifications of the laboratory Director or
non-physician practitioner personnel of an independent clinical laboratory.
Mandatory, if aPPliCaBle
Copy of IRS Determination Letter, if supplier is registered with the IRS as non-profit.
Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically
classified as a Disregarded Entity. (e.g., Form 8832).
(
A disregarded entity is an eligible entity that is treated as an entity not separate from its single
note:
owner for income tax purposes.
Statement in writing from the bank. If Medicare payment due a supplier of services is being sent to a
bank (or similar financial institution) with whom the supplier has a lending relationship (that is, any
type of loan), then the supplier must provide a statement in writing from the bank (which must be in
the loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables.
Copy(s) of all final adverse action documentation (e.g., notifications, resolutions, and
reinstatement letters).
Completed Form(s) CMS 855R, Reassignment of Medicare Benefits.
Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.
Copy of an attestation for government entities and tribal organizations.
Copy of FAA 135 certificate (air ambulance suppliers).
Copy(s) of comprehensive liability insurance policy (IDTFs only).
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938­
0685. The time required to complete this information collection is estimated to 6 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
do not Mail aPPliCationS to thiS addreSS. Mailing your application to this address will significantly delay application
processing.
CMS-855B (07/11)
35

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