Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 25
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27SECTION 15: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE
An AUTHORIZED OFFICIAL means an appointed official (for example, chief executive officer, chief financial
officer, general partner, chairman of the board, or 5% or greater direct owner) to whom the organization
has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the
organization’s enrollment information in the Medicare program, and to commit the organization to fully
abide by the statutes, regulations, and program instructions of the Medicare program.
By his/her signature, an authorized official binds the supplier to all of the requirements listed in the
Certification Statement and acknowledges that the supplier may be denied entry to or have its billing
privileges revoked from the Medicare program if any requirements are not met. All signatures must be
original and in blue ink. Faxed, photocopied, or stamped signatures will not be accepted.
By signing this application, an authorized official agrees to immediately notify the NSC MAC if any
information in this application is not true, correct, or complete. In addition, an authorized official, by his/
her signature, agrees to notify the NSC MAC of any future changes to the information contained in this
application after the supplier is enrolled in Medicare, within 30 days of the effective date of the change.
Applications submitted for initial enrollment must be signed by an Authorized Official or they will be rejected
and returned unprocessed.
The certification below includes additional requirements that the supplier must meet and maintain to bill
the Medicare program. Read these requirements carefully. By signing, you are attesting to having read the
requirements and understanding them.
Your signature further stipulates that you agree to adhere to all of the requirements listed below and
acknowledge that you may be denied entry into or have your billing privileges revoked from the Medicare
program if any requirements are not met.
A. CERTIFICATION STATEMENT
You MUST SIGN AND DATE Section 15B of this certification statement to become enrolled in the Medicare
program. In doing so, you are attesting to meeting and maintaining the Medicare requirements stated below.
Under penalty of perjury, 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 NSC MAC of this fact immediately.
2. I agree to notify the NSC MAC of any current or future changes to the information contained in this
application in accordance with the timeframes established in 42 C.F.R. section 424.57. I understand that
any change in the 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 identification
number(s), 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 1B 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 Stature, 42
U.S.C. section 1320a-7b(b) (section 1128B(b) of the Social security Act) and the Physician Self-Referral Law
(Stark Law), 42 U.S.C. section 1395nn (section 1877 of the Social Security Act)).
5. Neither this supplier, nor any five percent or greater owner, partner, officer, director, managing
employee, delegated official or authorized official thereof is currently sanctioned, suspended, debarred,
or excluded by Medicare or any state health care program (e.g., Medicaid program), or any other federal
program, or is otherwise prohibited from supplying services to Medicare or other federal program
beneficiaries. 6. I agree that any existing or future overpayment made to the supplier by the Medicare
program may be recouped by Medicare through the withholding of future payments.
7. 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.
8. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting
the Medicare program participation requirements, to release to any authorized representative,
employee, or agent of Medicare a copy of my most recent accreditation survey, together with any
information related to the survey that Medicare may require (including corrective action plans).
CMS-855S (05/16)
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