Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 46

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attaChMent 2: indePendent diagnoStiC teSting f aCilitieS
(Continued)
2
Personnel (technician) information
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)
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Social Security Number (Required)
Date of Birth (mm/dd/yyyy) (Required)
Is this technician State licensed or State certified? (see instructions for clarification)
YES
NO
License/Certification Number (if applicable)
License/Certification Issue Date (mm/dd/yyyy) (if applicable)
Is this technician certified by a national credentialing organization?
YES
NO
Name of credentialing organization (if applicable)
Type of Credentials (if applicable)
Is this technician employed by a hospital?
YES
NO
If yeS, provide the name of the hospital here: ________________________________________
e. Supervising Physicians
Complete this section with identifying information about the physician(s) who supervise the operation of
the IDTF and who provides the personal, direct, or general supervision per 42 C.F.R. 410.32(b)(3). The
supervising physician must also attest to his/her supervising responsibilities for the enrolling IDTF.
Information concerning the type of supervision (personal, direct, or general) required for performance of
specific IDTF tests can be obtained from your Medicare fee-for-service contractor. All IDTFs must report
at least one supervisory physician, and at least one supervising physician must perform the supervision
requirements stated in 42 C.F.R. 410.32(b)(3). All supervisory physician(s) must be currently enrolled
in Medicare.
The type of supervision being performed by each physician who signs the attestation on page 47 of this
application should be listed in this section.
Definitions of the types of supervision are as follows:
•
means a physician must be in attendance in the room during the performance of
Personal Supervision
the procedure.
•
means the physician must be present in the office suite and immediately available
direct Supervision
to provide assistance and direction throughout the performance of the procedure. It does not mean that
the physician must be present in the room when the procedure is performed.
•
means the procedure is provided under the physician’s overall direction and
general Supervision
control, but the physician’s presence is not required during the performance of the procedure. General
supervision also includes the responsibility that the non-physician personnel who perform the tests are
qualified and properly trained and that the equipment is operated properly, maintained, calibrated and
that necessary supplies are available.
CMS-855B (07/11)
45

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