Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 24
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27SECTION 14: ASSIGNMENT OF DELEGATED OFFICIAL(s)
(Optional)
A DELEGATED OFFICIAL means an individual who is delegated the authority to report changes and updates to
the supplier’s enrollment record by an authorized official. The delegated official must be an individual with
“ownership or control interest in” (as that term is defined in Section 1124(a)(3) of the Social Security Act) or
be a W-2 managing employee of the supplier. An independent contractor is not considered employed by the
supplier and therefore cannot be a delegated official.
Delegated officials may not delegate their authority to any other individual. Only an authorized official may
delegate the authority to make changes and/or updates to the supplier’s Medicare enrollment information.
Even when delegated officials are reported in this application, the authorized official retains the authority to
make changes and/or updates.
You are not required to have a delegated official. However, if no delegated official is assigned, the authorized
official(s) will be the only person(s) who can make changes and/or updates to the enrollment information.
The signature of a delegated official shall have the same force and effect as that of an authorized official,
and shall legally and financially bind the supplier to the laws, regulations, and program instructions of the
Medicare program. By his or her signature, a delegated official certifies that he or she has read the Penalties
for Falsifying Information in Section 13 and the Certification Statement in Section 15A and agrees to adhere
to all of the stated requirements. The delegated official also certifies that he/she meets the definition of
a delegated official. When making changes and/or updates to the supplier’s enrollment information, the
delegated official certifies that the information provided is true, correct and complete.
The signature of an authorized official in Section 14 constitutes a legal delegation of authority to all
delegated official(s) assigned in Section 14. If you are delegating more than two individuals, copy and
complete this section for each additional delegated individual.
NOTE: A delegated official who is being removed does not have to sign or date this application.
ASSIGNMENT OF DELEGATED OFFICIAL
All Delegated Officials must be reported in Section 9 of this application.
If you are adding or removing a delegated official, check the applicable box and furnish the effective date.
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Delegated Official’s Name and Signature
st
Add
Remove
Effective Date (mm/dd/yyyy):
Under penalty of perjury, I, the undersigned, certify that I have read and understand the Certification
Statement in Section 15A and accept the role of Delegated official.
Delegated Official First Name (Print)
Middle Initial
Last Name
Jr., Sr., M.D., etc.
Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)
Date Signed (mm/dd/yyyy)
Telephone Number
E-mail Address (if applicable)
Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., etc.)
Date Signed (mm/dd/yyyy)
2
Delegated Official’s Name and Signature
nd
Add
Remove
Effective Date (mm/dd/yyyy):
Under penalty of perjury, I, the undersigned, certify that I have read and understand the Certification
Statement in Section 15A and accept the role of Delegated official.
Delegated Official First Name (Print)
Middle Initial
Last Name
Jr., Sr., M.D., etc.
Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)
Date Signed (mm/dd/yyyy)
Telephone Number
E-mail Address (if applicable)
Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., etc.)
Date Signed (mm/dd/yyyy)
All signatures must be original. Applications with signatures deemed not original or not dated will not be processed.
Stamped, faxed or copied signatures will not be accepted.
CMS-855S (05/16)
23
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