Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 48

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attaChMent 2: indePendent diagnoStiC teSting faCilitieS
(Continued)
e. Supervising Physicians (Continued)
atteStation StateMent for SuPerViSing PhySiCianS
All Supervising Physician(s) rendering supervisory services for this IDTF must sign and date this section.
All signatures must be original.
1. I hereby acknowledge that I have agreed to provide (IDTF Name)___________________________
with the Supervisory Physician services checked above for all CPT-4 and HCPCS codes reported in
this Attachment. (See number 2 below if all reported CPT-4 and HCPCS codes do not apply). I also
hereby certify that I have the required proficiency in the performance and interpretation of each type
of diagnostic procedure, as reported by CPT-4 or HCPCS code in this Attachment (except for those
CPT-4 or HCPCS codes identified in number 2 below). I have read and understand the Penalties for
Falsifying Information on this Enrollment Application, as stated in Section 14 of this application. I
am aware that falsifying information may result in fines and/or imprisonment. If I undertake super-
visory responsibility at any additional IDTFs, I understand that it is my responsibility to notify this
IDTF at that time.
2. I am not acting as a Supervising Physician for the following CPT-4 and/or HCPCS codes reported in
this Attachment.
CPt–4 or hCPCS Code
CPt–4 or hCPCS Code
CPt–4 or hCPCS Code
3. Signature of Supervising Physician (First, Middle, Last, Jr., Sr., M.D., D.O., etc.)
Date (mm/dd/yyyy)
all signatures must be original and signed and dated 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)
47

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