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Last Modified: 9/19/2018 Location: FL, PR, USVI Business: Part A, Part B

Certification statement of the CMS-855

Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:

CMS-855A and CMS-855B

For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.

CMS-855C

For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.

CMS-855I

The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.

CMS-855POH

For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.
The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.
The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.

CMS-855R

For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.
If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.
The authorized or delegated official who signs section 6 must be currently on file with First Coast.

All CMS-855 applications

If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
Source: The Centers for Medicare & Medicare Services (CMS) internet-only manual (IOM) publication 100-08, chapter 15 external pdf file
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