Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 21

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SECtion 6: individualS having Managing Control
This section captures information about all managing employees. A managing employee means a general
manager, business manager, administrator, director, or other individual who exercises operational or
managerial control over, or who directly or indirectly conducts, the day-to-day operations of the supplier,
either under contract or through some other arrangement, regardless of whether the individual is a W-2
employee of the supplier.
All managing employees at any of your practice locations shown in Section 4 must be reported in this
section. If there is more than one managing employee, copy and complete this section as needed.
a. Managing Employee identifying information
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
Jr., Sr., etc. Title
Medicare Identification Number (if issued)
NPI (if issued)
Social Security Number (Required) Date of Birth (mm/dd/yyyy)
Place of Birth (State)
Country of Birth
What is the effective date this individual acquired managing control of the provider identified in Section 2A
of this application? (mm/dd/yyyy)
b. final adverse legal action history
Complete this section for the individual reported in Section 6A above. If you are changing or adding
information, check the “change” box, furnish the effective date, and complete the appropriate fields in
this section.
Change
Effective Date:______________________
1. Has this individual in Section 6A above, 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 him/her?
YES–Continue Below
NO–Skip to Section 8
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)
20

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