Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 16

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SECTION 7: FINAL ADVERSE LEGAL ACTIONS
This section captures information regarding final adverse legal actions such as convictions, exclusions,
revocations and suspensions. All applicable final adverse legal actions must be reported regardless of whether
any records were expunged or any appeals are pending.
A. CONVICTIONS
1. Any federal or state felony within the preceding 10 years.
2. Any misdemeanor conviction, under federal or state law, related to: (a) the delivery of an item or service
under Medicare or a state health care program, or (b) the abuse or neglect of a patient in connection
with the delivery of a health care item or service.
3. Any misdemeanor conviction, under federal or state law, related to theft, fraud, embezzlement, breach
of fiduciary duty, or other financial misconduct in connection with the delivery of a health care item
or service.
4. Any felony or misdemeanor conviction, under federal or state law, relating to the interference with
or obstruction of any investigation into any criminal offense described in 42 C.F.R. section 1001.101 or
1001.201.
5. Any felony or misdemeanor conviction, under federal or state law, relating to the unlawful manufacture,
distribution, prescription, or dispensing of a controlled substance.
B. EXCLUSIONS, REVOCATIONS, OR SUSPENSIONS
1. Any revocation or suspension of a license to provide health care by any state licensing authority. This
includes the surrender of such a license while a formal disciplinary proceeding was pending before a
state licensing authority.
2. Any revocation or suspension of accreditation.
3. Any suspension or exclusion from participation in, or any sanction imposed by, a federal or state health
care program, or any debarment from participation in any Federal Executive Branch procurement or non-
procurement program.
4. Any past or current Medicare and/or Medicaid payment suspension under any Medicare and/or Medicaid
billing number.
5. Any Medicare and/or Medicaid revocation of any Medicare and/or Medicaid billing number.
C. FINAL ADVERSE LEGAL ACTION HISTORY
If you are reporting a new final adverse legal action, check the box below and furnish the effective date.
New
Effective Date (mm/dd/yyyy):
1. Has the supplier identified in sections 1B/2A, under any current or former name or business identity, ever
had a final adverse legal action listed above imposed against it?
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 relevant final adverse legal action documents.
FINAL ADVERSE LEGAL ACTION
DATE
TAKEN BY
RESOLUTION
CMS-855S (05/16)
15

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Parent category: Medical