Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 20

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SECTION 9: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS)
(Continued)
A. INDIVIDUAL IDENTIFICATION INFORMATION (OWNERSHIP AND/OR MANAGING CONTROL)
If you need to report more than one individual, copy and complete this section for each.
If you are changing information about a currently reported individual owner or manager or adding or
removing an individual owner or manager, 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.
First Name
Middle Initial
Last Name
Jr., Sr.,M.D., etc.
Social Security Number (Required)
Date of Birth (mm/dd/yyyy)
Supplier Billing Number (if issued)
NPI (if issued)
Telephone Number
Fax Number (if applicable)
Email Address (if applicable)
2. What is the above individual’s title?
3. What is the above individual’s ownership interest in the supplier reported in Section 1B/2A?
5% or Greater Direct/Indirect Owner
Partner
4. What is the effective date the above individual acquired and/or ended the above ownership interest?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):
5. What is the above individual’s managing control of the supplier reported in Section 1B/2A?
(Check all that apply).
Officer
Contracted Managing Employee
Director
W-2 Managing Employee
6. What is the effective date the above individual acquired and/or ended the above managing control?
Acquired
Effective Date (mm/dd/yyyy):
Ended
Effective Date (mm/dd/yyyy):
7. Is the above individual also a Delegated Official or Authorized Official reported in Sections 14 or 15?
Delegated Official
Authorized Official
Neither
B. FINAL ADVERSE LEGAL ACTION HISTORY
Complete this section for the individual reported in Section 9A above.
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 individual reported in Section 9A, under any current or former name or business entity, ever had
a final adverse legal action listed in Section 7 of this application imposed against him/her?
YES–Continue Below
NO–Skip to Section 10
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)
19

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