08/21/2002 Enrollment Applilcation
Clerk olllle
Circul coun
Danny L. Kolhage
Clerk ofthe Circuit Court
Phone: (305)292-3550
FAX: (305) 295-3663
e-mail: phancock@monroe-clerk.com
Memorandum
TO: Reggie Paros, Director
Public Safety Division
ATTN: Stacy DeVane
Executive Assistant
FROM: Pamela G. Han"~
Deputy Clerk 'C:Y
DATE: September 6, 2002
At the August 21, 2002, Board of County Commissioner's meeting the Board granted
approval and authorized execution of the Medicare Federal Health Care Provider/Supplier Enrollment
Application in regards to ambulance billing services.
Enclosed is a certified copy of the above mentioned, as only one original was received, for your
handling. Should you have any questions please do not hesitate to contact this office.
Cc: County Administrator w/o document
County Attorney
Fi nance
File/
OMB Approval No.0938-0685
MEDICARE FEDERAL HEALTH CARE PROVIDER/SUPPLIER ENROLLMENT APPLICATION
Application for Health Care Suppliers that will Bill Medicare Carriers
General Instructions
The Medicare Federal Health Care Provider/Supplier Enrollment Application has been designed by the Centers for Medicare
& Medicaid Services (CMS)to assist in the administration of the Medicare program and to ensure that the Medicare program
is in compliance with all regulatory requirements. The information collected in this application will be used to ensure that
payments made from the Medicare trust fund are only paid to qualified health care suppliers, and that the amounts of the
payments are correct. This information will also identify whether the supplier is qualified to render health care services to
Medicare beneficiaries. To accomplish this, Medicare must know basic identifying and qualifying information about the
supplier that is seeking billing privileges in the Medicare program. If enrolling in the Medicare program as a supplier of
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) do not complete this application. DMEPOS
suppliers should contact the National Supplier Clearinghouse (NSC) at 803-754-3951 to obtain a CMS 855S for Medicare
enrollment.
Medicare needs to know: (1) the type of health care supplier enrolling, (2) what qualifies this supplier to furnish health care
related services, (3)where and how this supplier intends to render these services, and (4) those persons or entities with an
ownership interest, or managerial control, as defined in this application, over the supplier.
This application MUST be completed in its entirety, unless the appropriate box is checked to indicate the section does not
apply or when reporting a change to previously submitted information. If a section does not apply to this supplier, check ('l)
the appropriate box in that section and skip to the next section. Sections 7, 11, and 12 have been deliberately omitted from
this application because they are not applicable to the enrollment of suppliers that bill Medicare carriers.
1. General Application Information
This section is to be completed with general information as to why this application is being submitted and whether this
supplier currently has a business relationship with Medicare or any another Federal health care program.
To ensure timely processing of this application, Numbers 1, 2 and 3 below MUST ALWAYS be completed.
A. Reason for Submittal of this Application
1. Check one: ❑ Initial Enrollment ❑ Reactivation
Change of Information (Check appropriate Section(s) below and furnish this supplier's
Medicare Identification Number here): A0484
1 ® 2 ❑ 3 ® 4 1E15 ❑ 6 ❑ 8 ❑ 9 ❑ 10 ❑ 13 ® 15 ❑ 16
Attachment 1 - ❑ 1 ❑ 2 ❑ 3 ❑4 ❑ 5 ❑ 6 Attachment 2- ❑ 1 ❑ 2 ❑ 3 ❑4
❑Voluntary Termination of Billing Number—Effective Date (MM/DD/YYYY):
❑ Change of Ownership (Hospitals, Portable X-Ray Facilities, and
Ambulatory Surgical Centers)- Only
2. Tax Identification Number: 59-6000749
3. Is this supplier currently enrolled in the Medicare program? RYES ❑ NO
IF YES, furnish the following information about the current carrier:
Current Carrier Name: Monroe County EMS Current Medicare Identification Number: A0484
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2. Supplier Identification
This section is to be completed with information specifically related to the supplier submitting this application. Furnish the
following information about the supplier: (1) supplier type, (2) supplier name, and (3) the mailing address and telephone
number where Medicare can contact the supplier directly.
A. Type of Supplier ❑Change Effective Date:
The supplier must meet all Medicare requirements for the type of supplier checked below. If this supplier is a single
specialty clinic/group practice, the specialty must be reported. Submit copies of all required licenses, certifications, and
registrations with this application.
1. Type of Supplier(Check one):
M Ambulance Service Supplier El Multi-Specialty Clinic or Group Practice
❑Ambulatory Surgical Center ❑Occupational Therapy Group (complete#2 below)
❑Other Medical Care Group
❑ Diagnostic Radiology Group Practice/Clinic ❑ Physical Therapy Group (complete#2 below)
❑ Hospital Department(s), Hospital Outpatient Location(s)
and/or Hospital Clinic(s) (complete#4 below) ❑ Physiotherapy Group
❑ Independent Clinical Laboratory(CLIA) ❑ Portable X-ray Facility
ElIndependent Diagnostic Testing Facility(IDTF) ❑ Public Health/Welfare Agency
El Mammography Screening Center ❑Voluntary Health/Charitable Agency
❑ Managed Care Plan (non-Medicare +Choice) El*Single-Specialty Clinic/Group Practice:
❑ Mass Immunization Roster Biller Only Specify group/clinic specialty below:
❑ Medicare+Choice Organization
❑ Medical Faculty Practice Plan:
See instructions for specific documentation requirements ❑ Other(Specify):
2. PT/OT Groups ONLY-All occupational and physical therapy groups must answer the following questions:
a) Are all of the group's PT/OT services only rendered in patients' homes? ❑YES ❑ NO
b) Does this group maintain private office space? ❑ YES ❑ NO
c) Does this group own, lease, or rent its private office space? ❑ YES ❑ NO
d) Is this private office space used exclusively for the group's private practice? ❑YES ❑ NO
e) Does this group furnish PT/OT services outside of its office and/or patients' homes? ❑YES ❑ NO
IF YES, provide a copy of the lease agreement which gives the group exclusive use of the facility for PT/OT services.
3. Will this supplier be receiving reassigned benefits from individual practitioners? ❑YES ® NO
IF YES, submit a CMS 855R for each individual practitioner who will be reassigning benefits to this supplier.
4. Hospitals Only- If this supplier is a hospital applying for a billing number(s)for Part B practitioner services, check the
appropriate box below. See instructions before completing this section.
❑ Single billing number for all departments ❑ Separate billing number for each department listed below
B. Supplier Identification Information ❑ Change Effective Date:
Furnish the supplier's legal business name (as reported to the IRS), "doing business as" name (name supplier generally
known by to the public), and the various operating dates and places of formal business registration and/or incorporation.
1. Legal Business Name as Reported to the IRS Date Business Started (MM/DD/YYYY)
MONROE COUNTY EMS
2. "Doing Business As"(DBA) Name(if applicable) County/Parish where DBA Name Registered
(if applicable)
3. Identify the type of organizational structure for this supplier(Check one):
❑ Corporation ❑ Partnership ® Other(Specify): CITY/GOVERNMENT
4. Incorporation Date(if applicable)(MM/DD/YYYY) State where Incorporated (if applicable)
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OMB Approval No.0938-0685
2. Supplier Identification (Continued)
C. Correspondence Address IX] Change Effective Date: 7/10/02
This must be an address and telephone number where Medicare can contact this supplier directly.
Mailing Address Line 1
P.O. BOX 538
Mailing Address Line 2
City State ZIP Code +4
KEY WEST FL 33041
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
(800 ) 417-2165 ( ) (305 ) 521-0791 ADPADV5na BELLSOUTH.NET
D. Accreditation (Ambulatory Surgical Centers (ASCs) ONLY) ❑ Change Effective Date:
1. Is this supplier accredited? ❑YES ❑ NO
IF YES, complete the following: ❑ PENDING
2. Date of Accreditation (MM/DD/YYYY):
3. Name of Accrediting Body:
E. Comments
Explain any unique or unusual circumstances concerning the supplier's practice location(s), the method by which the
supplier renders health care services, or any special billing number requirements.
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3. Adverse Legal Actions and Overpayments
This section is to be completed with information concerning any adverse legal actions and/or overpayments that have been
imposed or levied against this supplier(see Table A below for list of adverse actions that must be reported).
A. Adverse Legal History ❑ Change Effective Date:
1. Has this supplier, under any current or former name or business identity, ever had any of the adverse legal actions
listed in Table A below imposed against it? ❑YES [ NO
2. IF YES, report each adverse legal action, when it occurred,the law enforcement authority/court/administrative body that
imposed the action, and the resolution. Attach a copy of the adverse legal action documentation(s)and resolution(s).
Adverse Legal Action: Date: Law Enforcement Authority: Resolution:
Table A
1)Any felony or misdemeanor conviction, under Federal or State law, related to: (a)the delivery of an item or service under
Medicare or a State health care program, or(b)the abuse or neglect of a patient in connection with the delivery of a health
care item or service.
2) Any felony or misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement, breach of
fiduciary duty,or other financial misconduct in connection with the delivery of a health care item or service.
3)Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or obstruction of any
investigation into any criminal offense described in 42 C.F.R. Section 1001.101 or 1001.201.
4) Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful manufacture, distribution,
prescription,or dispensing of a controlled substance.
5) Any revocation or suspension of a license to provide health care by any State licensing authority. This includes the
surrender of such a license while a formal disciplinary proceeding was pending before a State licensing authority.
6)Any revocation or suspension of accreditation.
7) Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or State health care program,
or any debarment from participation in any Federal Executive Branch procurement or non-procurement program.
8)Any current Medicare payment suspension under any Medicare billing number.
Note:All applicable adverse legal actions must be reported, regardless of whether any records
were expunged or any appeals are pending.
B. Overpayment Information ❑ Change Effective Date:
1. Does this supplier, under any current or former name or business identity, have any outstanding Medicare
overpayments? ❑YES ❑ NO
2. IF YES,furnish the name and account number under which the overpayment(s)exists.
Name under which the overpayment occurred: Account number under which the overpayment exists:
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4. Current Practice Location(s)
This section is to be completed with information about the physical location(s) where this supplier currently renders health
care services. If this supplier operates a mobile facility or portable units, furnish the address for the "Base of Operations,"
as well as vehicle information and the geographic area served by these facilities or units. In addition, cite where this
supplier wants its payments sent, and where the supplier maintains patients' medical records. If there is more than one
practice location, copy and complete this section for each.
A. Practice Location Information El Add El Delete El Change Effective Date:
1. Practice Location Name Date Started at this Location
(MM/DD/YYYY)
2. Practice Location Address Line 1
Practice Location Address Line 2
City County/Parish State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
3. Does this supplier own/lease this practice location? ❑ YES El NO
4. Is this practice location a: hospital? ❑ YES ❑ NO
retirement/assisted living community? El YES ❑ NO
group practice office/clinic ❑ YES ❑ NO
other health care facility? (Specify): El YES El NO
5. CLIA Number for this location (if applicable) FDA/Radiology (Mammography)Certification Number(s)for this
location (if applicable)
B. Mobile Facility and/or Portable Units El Change Effective Date:
Does this supplier furnish health care services from a mobile facility or portable unit? ❑ YES El NO
IF YES, use Sections 4C through 4E to furnish information about the mobile/portable services.
IF NO, proceed to Section 4F (Medicare Payment"Pay To"Address).
C. Base of Operations Address El Add El Delete El Change Effective Date:
The base of operations is the location from where personnel are dispatched, where mobile/portable equipment is stored
and, when applicable, where vehicles are parked when not in use. See instructions for further examples.
Check here ® and skip to Section 4D if the "Base of Operations" address is the same as the "Practice Location."
1. Base of Operations Name Date Started at this Location
(MM/DD/YYYY)
2. Street Address Line 1
Street Address Line 2
City County/Parish State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
D. Vehicle Information El Add El Delete El Change Effective Date:
If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish the following
vehicle information. See the instructions for a full explanation of the types of vehicles that need to be reported. If more
than three vehicles are used, copy and complete this section as needed.
1. Type of Vehicle (van, mobile home, trailer, etc.) Vehicle Identification Number
2. Type of Vehicle (van, mobile home, trailer, etc.) Vehicle Identification Number
3. Type of Vehicle (van, mobile home, trailer, etc.) Vehicle Identification Number
Note: For each vehicle, a copy of all health care related permits/licenses/registrations MUST be submitted.
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4. Practice Location (Continued)
E. Geographic Location where the Base of Operations and/or Vehicle Renders Services
❑Add ❑ Delete Effective Date:
Furnish the county/parish, city, State and ZIP Code for all locations where mobile and/or portable services are rendered.
Note: If this supplier renders mobile health care services in more than one State, and those States are served by
different Medicare contractors, a separate CMS 855B enrollment application must be completed for each Medicare
contractor jurisdiction.
1. Initial Reporting and/or Additions:
County/Parish: City: State: ZIP Code(s):
2. Deletions:
County/Parish: City: State: ZIP Code(s):
F. Medicare Payment "Pay To" Address X❑ Change Effective Date: 7/10/02
Furnish the address where payment should be sent for services rendered at the practice location(s) in Section 4A or 4C.
"Pay To"Address Line 1
P.O. BOX 538
"Pay To"Address Line 2
City State ZIP Code +4
KEY WEST FL 33041
Check here ❑ and complete and submit Form HCFA-588 with this application if the supplier would like its
payments electronically transferred to its bank account.
G. Location of Patients' Medical Records ❑ Add ❑ Delete ❑ Change Effective Date:
1. Check here® if all patients' medical records are stored at the location shown in Section 4A or 4C, and skip this section.
2. If ary of the patients' medical records are stored at a location other than the location shown in Section 4A or 4C,
complete this section with the name and address of the storage location.
Name of Storage Facility/Location
Storage Facility Address Line 1
Storage Facility Address Line 2
City State ZIP Code +4
H. Comments
Explain any unique or unusual circumstances concerning the supplier's practice location(s) or the method by which the
supplier renders health care services.
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5. Ownership Interest and/or Managing Control Information (Organizations)
This section is to be completed with information about all organizations that have 5% or more (direct or indirect) ownership
interest of, any partnership interest in, and/or managing control of, the supplier identified in Section 2B, as well as any
information on adverse legal actions that have been imposed against that organization. See instructions for examples of
organizations that should be reported here. If there is more than one organization, copy and complete this section for each.
A. Check here® if this section does not apply and skip to Section 6.
B. Organization with Ownership Interest and/or Managing Control—Identification Information
❑Add ❑ Delete ❑ Change Effective Date:
1. Check all that apply: ❑ 5% or more Ownership Interest Effective Date of Ownership
❑ Managing Control ❑ Partner (MM/DD/YYYY)
2. Legal Business Name Effective Date of Control
(MM/DD/YYYY)
3. "Doing Business As" Name (if applicable) Tax Identification Number
4. Business Address Line 1 Medicare Identification Number(s)(if
applicable)
Business Address Line 2
City State ZIP Code +4
C. Adverse Legal History ❑ Change ❑ Effective Date:
This section is to be completed only if the organization in Section 5B above is a 5% or greater owner (direct or indirect) of
the supplier identified in Section 2B, or has a partnership interest in the supplier identified in Section 2B.
1. Has the organization in Section 5B above, under any current or former name or business identity, ever had any of the
adverse legal actions listed in Table A in Section 3A imposed against it? ❑ YES ❑ NO
2. IF YES, report each adverse legal action, when it occurred, the law enforcement authority/court/administrative body that
imposed the action, and the resolution. Attach a copy of the adverse legal action documentation(s) and resolution(s).
Adverse Legal Action: Date: Law Enforcement Authority: Resolution:
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I6. Ownership Interest and/or Managing Control Information (Individuals)
This section is to be completed with information about any individual that has a 5% or greater(direct or indirect) ownership
interest in, or partnership interest in, the supplier identified in Section 2B. All officers, directors, and managing
employees of the supplier must also be reported in this section. In addition, any information on adverse legal actions that
have been imposed against the individuals reported in this section must be furnished. If there is more than one individual,
copy and complete this section for each.
A. Individual with Ownership Interest and/or Managing Control—Identification Information
❑Add ❑ Delete ❑Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Credentials (M.D.,
O.D., etc.)
Medicare Identification Number(if Effective Date of Ownership Effective Date of Control
applicable) (MM/DD/YYYY) (MM/DD/YYYY)
2. If the above individual is directly associated with the supplier in Section 2B, what is this individual's relationship with
the supplier? (Check all that apply.)
❑ 5%or Greater Owner ❑ Partner ❑ Managing Employee
❑ Director/Officer ❑ Other(Specify):
3. If the above individual is directly associated with an organization identified in Section 5B, furnish the name of that
organization in the space below:
Legal Business Name of Organization:
4. What is this individual's role with the organization reported in Section 6A3 above (check all that apply)?
❑ 5% or Greater Owner ❑ Partner ❑ Managing Employee
❑ Director/Officer ❑ Other(Specify):
B. Adverse Legal History LI Change ❑ Effective Date:
Please read the applicable instructions before completing this section. This section is to be completed only if the
individual in Section 6A above is a 5% or greater owner (direct or indirect), or has a partnership interest in, or is an actual
employee of,or director/officer of, the supplier identified in Section 2B.
1. Has the individual in Section 6A above, under any current or former name or business identity, ever had any of the
adverse legal actions listed in Table A in Section 3A imposed against him or her? ❑YES ❑ NO
2. IF YES, report each adverse legal action,when it occurred,the law enforcement authority/court/administrative body that
imposed the action, and the resolution. Attach a copy of the adverse legal action documentation(s)and resolution(s).
Adverse Legal Action: Date: Law Enforcement Authority: Resolution:
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7. Chain Home Office Information This Section Not Applicable
8. Billing Agency
This section is to be completed with information about all billing agencies this supplier uses or contracts with that submit
claims to Medicare on behalf of the supplier. If more than one billing agency is used, copy and complete this section for
each. The supplier may be required to submit a copy of its current signed billing agreement/contract if Medicare cannot
verify the information furnished in this section.
A. Check here ® if this section does not apply and skip to Section 9.
B. Billing Agency Name and Address ❑ Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS Tax Identification Number
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
C. Billing Agreement/Contract Information ❑ Change Effective Date:
Answer the following questions about the supplier's agreement/contract with the above billing agency.
1. Does the supplier have unrestricted access to its Medicare remittance notices? ❑YES ❑ NO
2. Does the supplier's Medicare payment go directly to the supplier? ❑ YES ❑ NO
IF NO, proceed to Question 3.
IF YES, skip Questions 3, 4 and 5.
3. Does the supplier's Medicare payment go directly to a bank? ❑YES ❑ NO
IF NO, proceed to Question 4.
IF YES, answer the following questions and skip Questions 4 and 5.
a) Is the bank account only in the name of the supplier? ❑YES ❑ NO
b) Does the supplier have unrestricted access to the bank account and statements? ❑ YES ❑ NO
c) Does the bank only answer to the supplier regarding what the supplier wants from the
bank(e.g., sweep account instructions, bank statements, closing account, etc.)? ❑ YES ❑ NO
4. Does the supplier's Medicare payment go directly to the billing agent? ❑ YES ❑ NO
IF NO, proceed to Question 5.
IF YES, answer the following question and skip Question 5.
a) Does the billing agent cash the supplier's check? ❑ YES ❑ NO
IF NO, proceed to Question b.
IF YES, are all of the following conditions included in the billing agreement?
1) The agent receives payment under an agency agreement with the supplier.
2) The agent's compensation is not related in any way to the dollar amounts billed
or collected.
3) The agent's compensation is not dependent upon the actual collection of payment.
4) The agent acts under payment disposition instructions that the supplier may
modify or revoke at any time.
5) In receiving payment, the agent acts only on behalf of the supplier(except
insofar as the agent uses part of that payment as compensation for the agent's
billing and collection services). ❑ YES ❑ NO
b) Does the billing agent either give the Medicare payment directly to this supplier or deposit
the payment into this supplier's bank account? ❑YES ❑ NO
5. Who receives the supplier's Medicare payment?
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9. Electronic Claims Submission Information
This section is to be completed with information about any company (clearinghouse)this supplier uses or contracts with for
electronic claims submission services. See the instructions to determine when and how this section is to be completed. If
this supplier submits (or will be submitting) claims electronically without the use of a 3rd party company (clearinghouse),
check the box in Section 9A and submit a copy of the supplier's electronic data interchange (EDI) agreement if one has
been established or check the box in Section 9B to start the EDI agreement process. If more than three clearinghouses are
used, copy and complete this section as needed.
A copy of all currently established EDI agreements for this supplier MUST be submitted with this application.
A. Check here ® if this section does not apply and skip to Section 10.
B. Check here ❑ if enrolling in Medicare for the first time and would like to submit claims electronically.
C. 15`Clearinghouse Name and Address ❑Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS Tax Identification Number
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
D. 2nd Clearinghouse Name and Address ❑Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS Tax Identification Number
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
E. 3rd Clearinghouse Name and Address ❑Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS Tax Identification Number
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State ZIP Code +4
•
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) (
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10.Staffing Company
This section is to be completed with information about all staffing companies that use this supplier, either under written
contract or by some other arrangement, to staff any other health care facilities. If this supplier is used by more than two
staffing companies, copy and complete this section as needed. The supplier may be required to submit a copy of its current
signed staffing company agreement/contract(s).
A. Check here® if this entire section does not apply and skip to Section 13.
B. 1st Staffing Company using this Supplier-Name and Address
❑ Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS Tax Identification Number
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
C. 1st Staffing Company using this Supplier-Contract/Agreement Information
Answer the following questions about the staffing company and the supplier's contract/agreement with them.
1. Does the staffing company shown in Section 10B above and the billing agency identified in Section 8B have a common
owner(s)? ❑
YES ❑ NO
2. If applicable, are there any provisions in the staffing contract/agreement that supersede or contradict the enrolling
supplier's billing agreement? ❑ Not applicable ❑ YES ❑ NO
D. 2nd Staffing Company using this Supplier-Name and Address
❑Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS Tax Identification Number
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State ZIP Code +4
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
( ) ( ) ( )
E. 2nd Staffing Company using this Supplier-Contract/Agreement Information
Answer the following questions about the staffing company's contract/agreement with this supplier.
1. Does the staffing company shown in Section 10D above and the billing agency identified in Section 8B have a common
owner(s)? ❑ YES ❑ NO
2. If applicable, are there any provisions in the staffing contract/agreement that supersede or contradict the enrolling
supplier's billing agreement? ❑ Not applicable ❑YES ❑ NO
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11.Surety Bond Information This Section Not Applicable
12.Capitalization Requirements for Home Health Agencies This Section Not Applicable
13.Contact Person(s)
Furnish the name(s) and telephone number(s) of a person(s)who can answer questions about the information furnished in
this application. If a contact person is not furnished in this section, all questions will be directed to the authorized official
named in Section 15B.
A. Check here ❑ if this section does not apply and skip to Section 14.
B. 1st Contact Name and Telephone Number 0 Add ❑ Delete ❑ Change Effective Date:
Name: First Last E-mail Address (if applicable) Telephone Number (Ext.)
James R. Paros irtarosC ii.l.state.fl.us (305 )289-6002 ( )
C. 2nd Contact Name and Telephone Number❑Add 0 Delete ❑ Change Effective Date:
Name: First Last E-mail Address (if applicable) Telephone Number (Ext.)
( ) ( )
114.Penalties for Falsifying Information on this Enrollment Application
This section explains the penalties for deliberately furnishing false information to gain enrollment in the Medicare program.
1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any
department or agency of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme
or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false
writing or document knowing the same to contain any false,fictitious or fraudulent statement or entry.
Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are
subject to fines of up to$500,000(18 U.S.C. §3571). Section 3571(d)also authorizes fines of up to twice the gross gain derived by the
offender if it is greater than the amount specifically authorized by the sentencing statute.
2. Section 1128B(a)(1)of the Social Security Act authorizes criminal penalties against any individual who, "knowingly and
willfully,"makes or causes to be made any false statement or representation of a material fact in any application for any
benefit or payment under a Federal health care program.
The offender is subject to fines of up to$25,000 and/or imprisonment for up to five years.
3. The Civil False Claims Act, 31 U.S.C. §3729, imposes civil liability, in part, on any person who:
a.) knowingly presents, or causes to be presented, to an officer or any employee of the United States Government
a false or fraudulent claim for payment or approval;
b.) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent
claim paid or approved by the Government; or
c.) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of damages sustained by the
Government.
4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including an organization,
agency or other entity) that knowingly presents or causes to be presented to an officer, employee, or agent of the
United States, or of any department or agency thereof, or of any State agency...a claim...that the Secretary determines
is for a medical or other item or service that the person knows or should know:
a.) was not provided as claimed; and/or
b.) the claim is false or fraudulent.
This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment of up to three times the
amount claimed,and exclusion from participation in the Medicare program and State health care programs.
5. The government may assert common law claims such as "common law fraud," "money paid by mistake," and "unjust
enrichment."
Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the unjust profit.
37 CMS 855B(11/2001)
OMB Approval No.0938-0685
16.Delegated Official (Optional)
The signature of the authorized official below constitutes a legal delegation of authority to the official(s) named in this
section to make changes and/or updates to this supplier's enrollment information. The signature(s) of the delegated
official(s) shall have the same force and effect as that of the authorized official, and shall legally and financially bind the
supplier to the laws, regulations, and program instructions of the Medicare program. By his or her signature,the delegated
official certifies that he or she has read the Certification Statement in Section 15 and agrees to adhere to all of the stated
requirements. The delegated official also certifies that he/she meets the definition of a delegated official. When making
changes and/or updates to the supplier's enrollment information maintained by the Medicare program, the delegated official
certifies that the information provided is true, correct, and complete. If assigning more than one delegated official
(maximum of three), copy and complete this section as needed.
A. Check here El if this supplier will not be assigning any delegated official(s) and skip to Section 17.
B. Delegated Official Signature El Add El Delete El Change Effective Date:
1. Delegated Official Name First Middle Last Jr., Sr., etc.
Print
Delegated Official (First, Middle, Last,Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY)
Signature Signed
Title/Position ❑Check here only if Delegated Official
is a W-2 employee*
2. Signature of Authorized Official (First, Middle, Last,Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY)
Assigning this Delegation Signed
17.Attachments
This section is a list of documents that, if applicable, should be submitted with this completed enrollment application.
Place a check next to each document (as applicable or required) from the list below that is being included with this
completed application.
❑Copy(s)of all Federal, State, and/or local (city/county)professional licenses, certifications and/or registrations
specifically required to operate as a health care facility
❑Copy(s)of all Federal, State, and/or local (city/county) business licenses, certifications and/or registrations
specifically required to operate as a health care facility
❑Copy(s)of all professional school degrees or certificates, or evidence of qualifying course work
❑Copy(s)of all documentation verifying IDTF Supervisory Physician(s)proficiency
❑Copy(s)of all CLIA Certificates, FDA Mammography Certificates, and Diabetes Education Certificates
ElCopy(s)of all State Pharmacy licenses
❑Copy(s)of all adverse legal action documentation (e.g., notifications, resolutions, and reinstatement letters)
❑Copy(s)of all current signed electronic data interchange (EDI)agreements
❑Copy(s)of all partnership agreements
❑Copy(s)of all articles of incorporation and/or corporate charters
❑Completed Form HCFA-588-Authorization Agreement for Electronic Funds Transfer
❑Completed Form(s)CMS 855R- Individual Reassignment of Benefits
❑IRS documents confirming the tax identification number and legal business name (e.g., CP 575)
❑Any additional documentation or letters of explanation as needed
ti
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45 CMS 855B(11/2001)
OMB Approval No.0938-0685
15.Certification Statement
This section is used to officially notify the supplier of additional requirements that must be met and maintained in order for
the supplier to be enrolled in the Medicare program. This section also requires the signature and date thereof of an
"Authorized Official" who can legally and financially bind the supplier to the laws, regulations, and program instructions of
the Medicare program. Section 16 permits the "Authorized Official" to delegate signature authority to other individual(s)
(Delegated Officials) employed by the supplier for the purpose of reporting future changes to the supplier's enrollment
record. See instructions to determine who qualifies as an Authorized Official and a Delegated Official for the supplier.
A. Additional Requirements for Medicare Enrollment
By his/her signature(s), the authorized official named below and the delegated official(s) named in Section 16
agree to adhere to the following requirements stated in this Certification Statement:
1.) I agree to notify the Medicare contractor of any future changes to the information contained in this form within 90 days
of the effective date of the change. I understand that any change in the business structure of this supplier may require
the submission of a new application.
2.) 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 revocation of Medicare
billing number(s), and/or the imposition of fines, civil damages, and/or imprisonment.
3.) I agree to abide by the Medicare laws, regulations and program instructions that apply to this supplier. The Medicare
laws, regulations, and program instructions are available through the Medicare 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 statute and the Stark law),
and on the supplier's compliance with all applicable conditions of participation in Medicare.
4.) Neither this supplier, nor any 5% or greater owner, partner, officer, director, W-2 managing employee, authorized
official, or delegated official thereof is currently sanctioned, suspended, debarred, or excluded by the Medicare or
Medicaid program, or any other Federal program, or is otherwise prohibited from supplying services to Medicare or
other Federal program beneficiaries.
5.) 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.
6.) 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.
B. Authorized Official Signature ❑ Add ❑ Delete ❑ Change Effective Date:
I have read the contents 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, to the best of my knowledge, and Ithorize the Medicare program
contractor to verify this information. If I become aware that any information in this application is not true, correct,
or complete. I aaree to notify the Medicare oroaram contractor of this fact immediately.
Authorized Official Name First Middle Last Jr., Sr., etc.
Print Charles 1`IcCoy
Authorized Official (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Title/Posi ' n Date (MM/D YYY)
Signature Mayor Signed Z(/v'
APPROVED AS TO FO
AND AL SUFFI
L t
ANNt 7TON
rc+trr 1_ flK fIATF �
41 CMS 855B(11/2001)