Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 14

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SECtion 3: final advErSE lEgal aCtionS/ConviCtionS
(Continued)
final advErSE lEgal aCtion hiStory
1. Have you, under any current or former name or business identity, ever had a final adverse legal action
listed on page 12 of this application imposed against you?
YES–Continue Below
NO–Skip to Section 4
2. If yes, report each final adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse legal action documentation and resolution.
final advErSE lEgal aCtion
datE
taKEn by
rESolution
CMS-855I (07/11)
13

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