Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 18

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SECTION 8: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
(Continued)
A. ORGANIZATION IDENTIFICATION INFORMATION (OWNERSHIP AND/OR MANAGING CONTROL)
Check here if this section is not applicable for the supplier reported in Sections 1B/2A, and skip to Section 9.
If you are changing information about a currently reported owning or managing organization or adding or
removing an owning or managing organization, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Change
Add
Remove
Effective Date (mm/dd/yyyy):
1. Complete all identifying information below.
Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Business Address Line 1 (Street Name and Number)
Business Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Tax Identification Number (Required)
NPI (if issued)
Medicare Identification Number(s) (if issued)
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
2. What is the above organization’s ownership interest in the supplier reported in Section 1B/2A?
5% or Greater Direct/Indirect Owner
Partner
Government/Tribal Owner
3. What is the effective date the above organization acquired and/or ended the above ownership interest?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):
4 What is the above organization’s managing control of the supplier reported in Section 1B/2A?
(Check all that apply)
Managing Organization
Board of Trustees
Governing Body
Controlling Entity (Gov’t/Tribe)
5. What is the effective date the above organization acquired and/or ended the above managing control?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):
B. FINAL ADVERSE LEGAL ACTION HISTORY
Complete this section for each organization reported in Section 8A.
If you are reporting a new final adverse legal action, check the box below and furnish effective date.
New
Effective Date (mm/dd/yyyy):
1. Has the organization in Section 8A above, under any current or former name or business identity, ever
had a final adverse legal action listed in Section 7 of this application imposed against it?
YES–Continue Below
NO–Skip to Section 9
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)
17

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