Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 26

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SECTION 15: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE
(Continued)
B. AUTHORIZED OFFICIAL SIGNATURE(S)
All Authorized Officials must be reported in Section 9 of this application.
If you are adding or removing an Authorized Official, check the applicable box and furnish the effective date.
1
st
Authorized Official
I have read the contents of this application and the certification statement in Section 15A of this application.
My signature legally and financially binds this supplier to the laws, regulations, and program instructions of
the Medicare program. By my signature, I certify that the information contained herein is true, correct, and
complete, and I authorize the NSC MAC to verify this information.
1
Authorized Official’s Information and Signature
st
Add
Remove
Effective Date (mm/dd/yyyy):
First Name (Print)
Middle Initial
Last Name (Print)
Jr., Sr., M.D., etc.
Telephone Number
E-mail Address (if applicable)
Title/Position
Authorized Official Signature (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.
2
Authorized Official
nd
I have read the contents of this application and the certification statement in Section 15A of this application.
My signature legally and financially binds this supplier to the laws, regulations, and program instructions of
the Medicare program. By my signature, I certify that the information contained herein is true, correct, and
complete, and I authorize the NSC MAC to verify this information.
2
Authorized Official’s Information and Signature
nd
Add
Remove
Effective Date (mm/dd/yyyy):
First Name (Print)
Middle Initial
Last Name (Print)
Jr., Sr., M.D., etc.
Telephone Number
E-mail Address (if applicable)
Title/Position
Authorized Official Signature (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.
3
rd
Authorized Official
I have read the contents of this application and the certification statement in Section 15A of this application.
My signature legally and financially binds this supplier to the laws, regulations, and program instructions of
the Medicare program. By my signature, I certify that the information contained herein is true, correct, and
complete, and I authorize the NSC MAC to verify this information.
3
Authorized Official’s Information and Signature
rd
Add
Remove
Effective Date (mm/dd/yyyy):
First Name (Print)
Middle Initial
Last Name (Print)
Jr., Sr., M.D., etc.
Telephone Number
E-mail Address (if applicable)
Title/Position
Authorized Official Signature (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)
25

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