) application.
Section of form |
Helpful hints |
|---|---|
Section 1: Basic information |
Section 1A: Check one box and complete the required sections Select the reason for submitting the application. Section 1B: Check all that apply and complete the required sections If you are performing a change of information, please select the sections you are changing: • Required sections for the change of information are listed in the right column |
Section 2: Identifying information |
Section 2A: Type of provider Indicate the provider type as either a type other than a hospital (list under 2A1) or a hospital (list under 2A2): • If the provider is a hospital, the question 2A3 must be answered • Answer whether the provider is a physician-owned hospital The provider must meet all Federal and State requirements for the type of provider checked. Section 2B: Identification information Legal business name must match exactly what is reported to the IRS. Provide the year end cost report date. Be sure to provide the state license or certification, if applicable: • Include a copy of the license or certification with the enrollment application Section 2C: Correspondence address Correspondence address is the address we can contact the supplier directly: • Address cannot be a billing agent or agency's address or a medical management company Section 2D: Medical record correspondence address Medical record correspondence address is the address we can contact the supplier directly for any medical record review requests: • Address cannot be a billing agent or agency's address or a medical management company Section 2E: Accreditation List any accreditation for the provider. Must be completed for those who select home health agency as the provider type. CMS recognizes the Joint Commission on Accreditation of Healthcare Organizations accreditation organization: • Refer to www.jointcommission.org Section 2F: Comments Section is used to clarify any information in this section. Section 2G: Change of ownership (CHOW) information Both the seller or former owner and the new owner must complete this application: • The seller or former owner must complete sections 1A, 2G, 13, and 15 • The new owner must complete the entire application A copy of the bill of sale must be submitted with the application. A copy of the final sales agreement must be submitted once the sale is executed. Section 2H: Acquisitions and mergers Both the seller or former owner (provider being acquired) and the new owner (acquiring provider) must complete information in this section: • The seller or former owner must complete sections 1A, 2H, 13, and either 15 or 16 • The new owner must complete sections 1A, 2H, 4, 13, and 15 A copy of the bill of sale must be submitted with the application. A copy of the final sales agreement must be submitted once the sale is executed. Section 2I: Consolidations Providers being consolidated are reported in sections 2I1 and 2I2: • The newly formed provider completes the entire application In section 2I3, the newly created provider must report the legal business name as reported to the IRS. Be sure to include the tax identification number. A copy of the bill of sale must be submitted with the application. A copy of the final sales agreement must be submitted once the sale is executed. |
Section 3: Final adverse legal actions/ convictions |
Make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. |
Section 4: Practice location information |
Section 4A: Practice location information If you or your organization sees patients in more than one practice location, copy and complete this section for each location. Be sure to include the date you saw your first Medicare patient at this location. Hospitals and home health agencies must identify the type of practice location. Note: If your organization is going through a change of ownership (CHOW), merger, or consolidation, the effective date of each practice location should reflect the date the location was established and not the date of sale. Section 4B: Where do you want remittance notices or special payments sent? Provide address where payment information (e.g., remittance notices, non-routine special payments) should be sent. Section 4C: Where do you keep patients' medical records If you store patients' medical records at a location other than the location in section 4A or store patients’ medical records electronically, complete this section with the address or service of the storage location. P.O. boxes and drop boxes are not acceptable for the medical records storage location. Section 4D: Base of operations address for mobile or portable providers The base of operations is the location from where personnel are dispatched, where mobile or portable equipment is stored, and when applicable, where vehicles are parked when not in use. Section 4E: Vehicle information This section is applicable to mobile vehicles where health care services are provided: • This section is not applicable to vehicles that are used only to transport medical equipment (e.g., transported in a van, but used in a fixed setting) If more than three vehicles are used, copy this section, and complete it for each additional vehicle. Section 4F: Geographic location for mobile or portable providers where the base of operations and/or vehicle renders services For home health agencies and mobile or portable providers, furnish information identifying the geographic area(s) where health care services are rendered. If you are initially reporting or adding an entire state or territory, check the applicable box and furnish the state or territory. If you are not servicing an entire state or territory, provide the city or town or county where you provide services: • Only list the ZIP codes if you are not servicing the entire city or town or county |
Section 5: Ownership interest and/or managing control information (organizations) |
This section only applies to organizations. Any organization that exercised operational or managerial control over the provider or conducts the day-to-day operations, is a managing organization. Note: If you are a skilled nursing facility (SNF), please check the top box and skip this section. All ownership interest and managing control information must be reported in Attachment 1. Section 5A: Ownership and/or managing control organization Enter the legal business name as reported to the IRS. If there is another name the provider uses, enter this in the Doing business as box. Section 5B: Ownership and/or managing control information Mark all applicable ownership or managerial control types applicable for the organization. Organizational diagram must be submitted when section 5 is completed. Section 5C: Chain Home Office Specify the type of action the provider is reporting, effective date of this action, and then complete the applicable fields about the chain home office: • For initial enrollment, complete all sections • For a change of information, complete the elements that are changing Section 5D: Final adverse legal action history Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. |
Section 6: Ownership interest and/or managing control information (individuals) |
Note: If you are a skilled nursing facility, please check the top box and skip this section. All ownership interest and managing control information must be reported in Attachment 1. Section 6A: Identifying information The name, date of birth, and social security number of each person listed in this section must coincide with the individual's information listed with the Social Security Administration. Note: If you are a managing employee, you must provide an effective date in section 6A under the W-2 managing employee role. We understand there is confusion as the effective date field states "Effective date of 5% or greater direct ownership interest"; however, the effective date of when this individual accepted the managing employee role should be reported on this line. It is a required field that needs completed before we can approve the application. For Hospices who are reporting a managing employee, make sure to check the applicable box if the managing employee is a medical director or administrator. Section 6B: Final adverse legal action history Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable |
Section 8: Billing agency information |
A billing agency is a company or individual you contract with to prepare and submit your claims: • If you are using a billing agency, you are responsible for the claims submitted on your behalf |
Section 10: Opioid Treatment Program Personnel |
The OTP must include the following information for all employees and contracted staff, whether W-2 or not, who are legally authorized to order controlled substances, whether or not the individual is currently ordering at the OTP facility. A. Ordering personnel identification Copy and complete this section if more than three OTP ordering personnel need to be reported. B. Dispensing personnel identification Copy and complete this section if more than three OTP dispensing personnel need to be reported. |
Section 12: Special requirements for home health agencies (HHAs) |
All home health agencies and home health agency sub-units enrolling in the Medicare program must complete this section. To assist in determining the home health agency or home health agency sub-units have the required funds, complete the requested information on type of HHA/sub-unit, number of visits projected, business structure, use of nursing registry, etc. Please submit financial documentation. |
Section 13: Contact person |
Captures the person we will contact about the application. Be sure to include all information, including the e-mail address. |
Section 14: Penalties for falsifying information |
This section explains the penalties for deliberately furnishing false information: • Read this section as it outlines criminal penalties and civil liability on individuals who knowingly furnish false information |
Section 15: Certification statement |
Please include section 15A in addition to the signature page. For initial enrollments, all individuals listed in section 6 as an authorized official, must sign section 15B. For initial enrollments, all individuals listed in section 6 as an delegated official, must sign section 15C. All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures are not acceptable. |
Section 17: Supporting documents |
• Licenses, certifications and registrations required by Medicare or State law • Federal, State/Territory, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health care facility • Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g., IRS CP 575) provided in section 2A • Completed Form CMS-588, Authorization Agreement for Electronic Funds Transfer. Include a voided check or bank letter CMS-588 external_pdf.gif) NOTE: If a provider already receives payments electronically and is not making a change to its banking information, the CMS-588 is not required. • Copy(s) of all bills of sale or sales agreements for all ownership changes. This includes CHOWS, Acquisition/Mergers, Consolidations, and all other ownership changes that are required to be reported, regardless of the percentage involved (e.g., new 15 percent owner). • Copy(s) of all documents that demonstrate meeting capitalization requirements (HHAs only) • If Medicare payment due a provider of services is being sent to a bank (or similar financial institution) with whom the provider has a lending relationship (that is, any type of loan), the provider must provide a statement in writing from the bank (which must be in the loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables • Copy(s) of all final adverse legal action documentation (e.g., notifications, resolutions, and reinstatement letters) • Copy of an attestation for government entities and tribal organizations • Copy of HRSA Notice of Grant Award if that is a qualifying document for FQHC status • Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit (e.g., IRS Form 501(c)(3)) • Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity (e.g., Form 8832, if applicable) NOTE: A disregarded entity is an eligible entity that is not treated as a separate entity from its single owner for income tax purposes. • Organizational structure diagram/flowchart identifying all of the entities listed in section 5 and their relationships with the provider and each other • Copy of all mobile vehicle registrations (all mobile services) • Rural Emergency Hospital (REH) Action Plan |
Attachment 1: Skilled nursing facility disclosures |
All skilled nursing facilities (SNFs) must complete this attachment with their application during: • Initial enrollment • Revalidation • Change of information (though only with respect to the information that is changing) • Change of ownership (CHOW) A. Organization identification information Indicate if you have no organizations with ownership or managing control to report B. Type of organization Complete this section with information for the organization listed in Section A C. Chain home offices only If you’re a chain home office, we’ll use the information you provide to ensure proper reimbursement when the provider files their year-end cost report with the MAC D. Relationship to the SNF and/or to additional disclosable party (ADP) of the SNF Questions 1–7 should only be completed if it applies to your business structure. Furnish the additional information, including the effective date and exact percentage of ownership, if applicable. Combined percentage totals for direct owners can’t exceed 100%. E. Final Adverse legal action Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable Individual Instructions A. Individual identifying information Check this box if you have no individuals with ownership or managing control to report, if you do complete the section B. Relationship to SNF and/or additional disclosable party (ADP) or SNF Identify the type of interest the individual in section A has in the SNF. Questions 1–7 should only be completed if they apply to the SNF’s business structure. Furnish the additional information, including the effective date and exact percentage of ownership, if applicable. Combined percentage totals for direct owners can’t exceed 100%. C. Final Adverse legal action Complete this section for the individual you reported in section A. For information on what to report refer to section 3 of this application |
