Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 26
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28SECtion 15: CErtifiCation StatEMEnt
(Continued)
As an individual practitioner, you are the only person who can sign this application. The authority to sign
the application on your behalf may not be delegated to any other person.
The Certification Statement contains certain standards that must be met for initial and continuous
enrollment in the Medicare program. Review these requirements carefully.
By signing the Certification Statement, you agree to adhere to all of the requirements listed therein and
acknowledge that you may be denied entry to or revoked from the Medicare program if any requirements
are not met.
Certification Statement
You MUST sign and date the certification statement below in order to be enrolled in the Medicare program.
In doing so, you are attesting to meeting and maintaining the Medicare requirements stated below.
I, the undersigned, certify to the following:
1. I have read the contents of this application, and the information contained herein is true, correct, and
complete. If I become aware that any information in this application is not true, correct, or complete, I
agree to notify the Medicare fee-for-service contractor of this fact in accordance with the time frames
established in 42 CFR § 424.516.
2. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the
Medicare contractor of a change in ownership, practice location and/or Final Adverse Action within 30
days of the reportable event. In addition, I agree to notify the Medicare contractor of any other changes to
the information to this form within 90 days of the effective date of change. I understand that any change
to my status as an individual practitioner may require the submission of a new application. I understand
that any change in business structure of this supplier may require the submission of a new application.
3. I have read and understand the Penalties for Falsifying Information, as printed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information
contained in this application or contained in any communication supplying information to Medicare,
or any deliberate alteration of any text on this application form, may be punished by criminal, civil,
or administrative penalties including, but not limited to, the denial or revocation of Medicare billing
privileges, and/or the imposition of fines, civil damages, and/or imprisonment.
4. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to the
organization listed in Section 4A of this application. The Medicare laws, regulations, and program
instructions are available through the fee-for-service contractor. I understand that payment of a claim
by Medicare is conditioned upon the claim and the underlying transaction complying with such laws,
regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and
the Stark law), and on the supplier’s compliance with all applicable conditions of participation
in Medicare.
5. N either I, nor any managing employee listed on this application, is currently sanctioned, suspended,
debarred, or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or any
other Federal program, or is otherwise prohibited from providing services to Medicare or other Federal
program beneficiaries.
6. I agree that any existing or future overpayment made to me (or to the organization listed in Section 4A
of this application) by the Medicare program may be recouped by Medicare through the withholding of
future payments.
7. I understand that the Medicare identification number issued to me can only be used by me or by a
provider or supplier to whom I have reassigned my benefits under current Medicare regulations, when
billing for services rendered by me.
8. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by
Medicare, and will not submit claims with deliberate ignorance or reckless disregard of their truth
or falsity.
9. I further certify that I am the individual practitioner who is applying for Medicare billing privileges.
CMS-855I (07/11)
25
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