Form Cms-460 - Medicare Participating Physician Or Supplier Agreement

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB NO. 0938-0373
MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
Name(s) and Address of Participant*
National Provider Identifier (NPI)*
*List all names and the NPI under which the participant files claims with the Medicare Administrative Contractor (MAC)/carrier
with whom this agreement is being filed.
The above named person or organization, called “the participant,” hereby enters into an agreement with the Medicare
program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to
accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect.
1. Meaning of Assignment: For purposes of this agreement, accepting assignment of the Medicare Part B
payment means requesting direct Part B payment from the Medicare program. Under an assignment, the
approved charge, determined by the MAC/carrier, shall be the full charge for the service covered under Part B.
The participant shall not collect from the beneficiary or other person or organization for covered services more
than the applicable deductible and coinsurance.
2. Effective Date: If the participant files the agreement with any MAC/carrier during the enrollment period, the
agreement becomes effective __________________.
3. Term and Termination of Agreement: This agreement shall continue in effect through December 31 following
the date the agreement becomes effective and shall be renewed automatically for each 12-month period January
1 through December 31 thereafter unless one of the following occurs:
a. During the enrollment period provided near the end of any calendar year, the participant notifies
in writing every MAC/carrier with whom the participant has filed the agreement or a copy of the
agreement that the participant wishes to terminate the agreement at the end of the current term. In the
event such notification is mailed or delivered during the enrollment period provided near the end of
any calendar year, the agreement shall end on December 31 of that year.
b. The Centers for Medicare & Medicaid Services may find, after notice to and opportunity for a hearing
for the participant, that the participant has substantially failed to comply with the agreement. In the
event such a finding is made, the Centers for Medicare & Medicaid Services will notify the participant
in writing that the agreement will be terminated at a time designated in the notice. Civil and criminal
penalties may also be imposed for violation of the agreement.
Signature of participant (or authorized representative of participating organization)
Date
Title (if signer is authorized representative of organization)
Office Phone Number (including area code)
Received by (name of carrier)
Initials of Carrier Official
Effective Date
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-0373. The time required to complete this
information collection is estimated to average 15 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Baltimore, Maryland 21244-1850.
Form CMS-460 (04/10)
1

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