Item C35MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: August 21, 2002 Division: Public Safety
Bulk Item: Yes X No Department: EMS
AGENDA ITEM WORDING: Approval for Mayor to execute Medicare Federal Health Care
Provider/Supplier Enrollment Application in regards to ambulance billing services
ITEM BACKGROUND: The location of the ambulance billing lockbox is being changed from
a Miami address to a Key West address. The attached Medicare Federal Health Care
Provider/Supplier Enrollment Application is required to ensure that all correspondence/remittance
goes to the proper address.
PREVIOUS RELEVANT BOCC ACTION: Not applicable
CONTRACT/AGREEMENT CHANGES: This is not a contract
STAFF RECOMMENDATION: Approval
TOTAL COST: 0.00 BUDGETED: Yes No
COST TO COUNTY: 0.00
REVENUE PRODUCING: Yes No _ N/A
APPROVED BY: County Attorney YES OMB /Pur g sk Management N/A
DIVISION DIRECTOR APPROVAL: Z--
Ja es R. "Reggie" Paros
DOCUMENTATION: Included: X To Follow: Not Required:
DISPOSITION: Agenda Item #:��
Advanced Data Processing
July 25, 2002
Monroe County EMS
Attn: Stacey Devane
490 63'd Street Ocean
Marathon, FL 33050
Dear Stacey Devane:
Advanced Data Processing Phone 305 945 2280
520 NW 165 Street Road
Suite 201 Fax 305 521 0791
Miami, FL 33169 Email adpadv5@bellsouth.net
Subject: Lockbox Change of Address Forms for Medicare/Medicaid/Railroad Medicare
Due to Bank of America changing the location of the lockbox to a Key West address we must submit
the attached forms to ensure that all correspondence/remittance goes to the proper address.
Please find enclosed change of information forms for Medicare, Medicaid and Railroad Medicare.
Please have these forms completed as soon as possible (please have an authorized person sign forms
in blue ink) and send back to my attention. The following are included:
e CMS 855B Form — Complete highlighted areas.
Medicaid Change of Address Form — Complete highlighted areas and have notarized.
e Railroad Medicare Change of Information Form — Complete highlighted areas.
Again, forward the completed forms back to my attention. If you have any questions please feel free to
contact me at 800-226-1149.
Sincerely,
DqHart
Operations Manager
Advanced Data Processing
OMB Approval No. 0938-0685
MEDICARE.FEDERAL,HEALTH CARE ENROLLMENT ENROLLMENT APPLICATION
Application for.Healtfi Care Suppliers that will Bill Metlicare'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 (q)
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 02 ❑3 ®4 ❑5 ❑6 ❑8 09 ❑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? ® YES ❑ NO
IF YES, furnish the following information about the current carrier:
Current Carrier Name: Monroe County FAMS Current Medicare Identification Number: A0484
7 CMS 855B (11/2001)
OMB Approval No. 0938-0685
2. '3Supplier. lidentlticatlon
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
rPnistrations with this application.
1. Type of Supplier (Check one):
® Ambulance Service Supplier
❑ Ambulatory Surgical Center
❑ Diagnostic Radiology Group Practice/Clinic
❑ Hospital Department(s), Hospital Outpatient Location(s)
and/or Hospital Clinic(s) (complete # 4 below)
❑ Independent Clinical Laboratory (CLIA)
❑ Independent Diagnostic Testing Facility (IDTF)
❑ Mammography Screening Center
❑ Managed Care Plan (non -Medicare +Choice)
❑ Mass Immunization Roster Biller Only
❑ Medicare +Choice Organization
❑ M d' I Faculty Practice Plan:
❑ Multi -Specialty Clinic or Group Practice
❑ Occupational Therapy Group (complete # 2 below)
❑ Other Medical Care Group
❑ Physical Therapy Group (complete # 2 below)
❑ Physiotherapy Group
❑ Portable X-ray Facility
❑ Public Health/Welfare Agency
❑ Voluntary Health/Charitable Agency
❑ *Single -Specialty Clinic/Group Practice:
*Specify group/clinic specialty below:
e ica
See instructions for specific documentation requirements I ❑ Other (Specify):
2. PT/OT Groups ONLY - All occupational and physical therapy groups must answer the following questions
a) Are all of the group Is PT/OT services only rendered in patients' homes? YESE] NO
0 YES ❑ NO
b) Does this group maintain private office space? YES []NO
c) Does this group own, lease, or rent its private office space? ❑
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)
2. "Doing Business As" (DBA) Name (if applicable)
3. Identify the type of organizational structure for this su
❑ Corporation ❑ Partnership
4. Incorporation Date (if applicable) (MM/DD/YYYY)
County/Parish where DBA Name Registered
(if applicable)
Ot(Check one): CITY/GOVERNMENT
Other (Specify):
State where Incorporated (if applicable)
CMS 855B (11/2001)
OMB Approval No. 0938-0685
2. =Sup ji1j: ii ehfificaticn" Coiitinueci)
C. Correspondence Address [Z]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
KEY WEST
State
FL
ZIP Code + 4
1
Telephone Number (Ext.)
(0) 417-21 ( )
Fax Number (if applicable)
(5) 5 1-0791
E-mail Address (if applicable)
ADPADV50BELLS UTH.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.
11 CMS 855B (11/2001)
OMB Approval No. 0938-0685
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
A below for list of adverse actions that must be reported).
imposed or levied against this supplier (see Table
a Effective Date.
A. Adverse Legal History ❑ Change
1. Has this supplier, under any current or former name or business identity, ever had any of the adverse legal
actioNOns
listed in Table A below imposed against it?
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 documentations) 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 outstandingYES ❑ NO
re
❑
overpayments?
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:
13 CMS 855B (11/2001)
OMB Approval No. 0938-0685
4. �cenf i
Cu ,Iractice"Lo catio _
.v i!
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 ❑ Add ❑ Delete ❑ 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)
EE-mailress (if applicable)
3. Does this supplier own/lease this practice location? ❑ YES ❑ NO
4. Is this practice location a: hospital? ❑ YES ❑ NO
retirement/assisted living community? ❑ YES ❑ NO
group practice office/clinic ❑ YES ❑ NO
other health care facility? (Specify): ❑ YES ❑ NO
S. 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 ❑ Change Effective Date:
Does this supplier furnish health care services from a mobile facility or portable unit? ❑ YES ❑ 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 ❑ Add ❑ Delete ❑ 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
2. Street Address Line 1 (MM/DD/YYYY)
Street Address Line 2
City
County/Parish
State
ZIP Code + 4
Telephone Number (Ext7,F-axN)umber
(if applicable)
E-mail Address (if applicable)
D. Vehicle Information ❑ Add ❑ Delete ❑ 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
Vehicle Identification Number
2. Type of Vehicle (van, mobile home, trailer, etc.)
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/reaistratienc M1I-RT ha ah.,,i♦*sa
17 CMS 855B (11/2001)
OMB Approval No. 0938-0685
X.
E. Geographic Location'where the Base of Operations and/
4. Practice � 0C . 11-
or Vehicle Renders Services
❑ Add ❑ Delete Effective Date:
services tes are served by
Furnish the county/parish, city, State and ZIP Code for all locations where mobil and/or po those St
Note: If this supplier renders mobile health care services in more than one
different Medicare contractors, a separate CMS 855B enrollment application must be completed for each Medicare
contractor jurisdiction.
1. Initial Reportin4 and/or Additions: ZIP Code(s):
County/Parish:
City: State:
2. Deletions: City: State: ZIP Code(s):
County/Parish:
F. Medicare Payment "Pay To" Address
Change Effective Date: 7/10102
r services rendered at the practice location(s) in Section 4A or 4C.
Furnish the address where payment should be sent fo
"Pay To" Address Line 1 P.O. BOX 538
"Pay To" Address Line 2
State ZIP Code + 4
City t-L "•," ' '
KEY WEST application if the supplier would like its
Check here ❑ and complete and submit Form HCFA-588 with this
payments electronically transferred to its bank account. ❑ Change Effective Date:
Delete
G. Location of Patients' Medical Records ❑ Add ❑
rds are stored at the location shown in
4C, and skip this
1. Check here ® if all patients' medical recothe location sr
shown nSect on 4A or 4Csection.
2. If an of the patients' medical records are stored at a location other than
name and address of the storage location.
complete this section with the
Name of Storage Facility/Location
Storage Facility Address Line 1
Storage Facility Address Line 2
State
City
ZIP Code + 4
H. Comments supplier's practice locations) or the method by which the
Explain any unique or unusual circumstances concerning the supp
suoolier renders health care services.
CMS 855B (11/2001)
19
OMB Approval No. 0938-0685
5. Ownership; nterest and/or Managing°Controlanformatiorr (Organization's)
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:
25 CMS 855B (11/2001)
OMB Approval No. 0938=0685
6. Ownership nterest and/o01Aan60169,Control lnformation (Individuals)
This section is to be completed with information about
any
Ydentifiedainhat hasn 26 or greater
(dirers,dcteor in rand manag nlg
interest in, or any partnership interest in, the supplier
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.)
Effective Date of Control
Medicare Identification Number (if Effective Date of Ownership MMlDD/YYYY)
applicable) (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.) ManagingEmployee
❑ 5% or Greater Owner Other Partner
❑
❑ Director/Officer ❑ (Specify):—
3. If the above individual is direct) associated with an organization identified in Section 56, 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)?
a Partner ❑ Managing Employee
❑ 5 /o or Greater Owner
❑ Director/Officer ❑ Other (Specif
y):
B. Adverse Legal History
❑ Change ❑ Effective Date:
Please read the applicable instructions before completing this section. This section is to be completed onlyif 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
occurred, the law enforcement
ve
that
2. IF YES, report each adverse legal acn, when
the resolution Attach at copy of he adverse legal action documentation ts
mentation(s) andreoluti(
ons).
imposed the action, a
Adverse Legal Action: Date: Law Enforcement Authority: Resolution:
29 CMS 855B (11/2001)
OMB Approval No. 0938-0685
7. :Chain"Home Office,information :: "This'Sedion 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?
31 CMS 855B (11/2001)
OMB Approval No. 0938-0685
9. "Electronid,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 bcomplet
ed.
lf
this supplier submits (or will be submitting) claims electronically without the use of a Td 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
B to start the EDI agreement process. If more than three clearinghouses are
been established or check the box in Section 9
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. I" 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
Telephone Number (Ext.) Fax Number (if applicable)
D. 2"d Clearinghouse Name and Address ❑Add
Ej Delete
1. Legal Business Name as Reported to the IRS
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City
State
Telephone Number (Ext.) Fax Number (if applicable)
( ) ( ) ( )
E. 3`d Clearinghouse Name and Address ❑Add
Delete
1: Legal Business Name as Reported to the IRS
2. "Doing Business As" Name (if applicable)
3. Business Street Address Line 1
Business Street Address Line 2
City State
Telephone Number (Ext.) Fax Number (if applicable)
33
ZIP Code + 4
E-mail Address (if applicable)
❑ Change Effective Date:
Tax Identification Number
ZIP Code + 4
E-mail Address (if applicable)
❑ Change Effective Date:
Tax Identification Number
ZIP Code + 4
E-mail Address (if applicable)
CMS 855B (11/2001)
OMB Approval No. 0938-0685
40.Staffirig'Company z - N
� :,� � 4 .�� � �u� � � � � �...������.�,�:
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. Vt Staffing Company using this Supplier - Name and Address
❑ Add ❑ Delete ❑ Change Effective Date:
1. Legal Business Name as Reported to the IRS I 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. 1" 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. 2"d 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)
"d E. 2Staffing 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
35 CMS 855B (11/2001)
OMB Approval No. 0938-0685
11. Surety Bond Information
12.Capitalization Requirements for Home
This Section Not
This Section Not Applicable
13. Contact Person(s)
Fu rnish the name(s) and telephone numbers) 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.
Delete ❑Change Effective Date:
B. 15L Contact Name and Telephone Number [] Add applicable) Telephone Number (Ext.)
Last E-mail Address (if app ' ) �S 289-6002
Name: First P r 'l.state.".us
Change
Effective Date:
C. 2nd Contact Name and Telephone Numbers Add E-mail Address (if applicable) Telephone Number (Ext.)
Name: First Last
Application
14. Penalties for Falsifying Information on this Enrollment
at opto ain enrollment in the Medicare program.
This section explains the penalties for deliberately furnishing false inform g an trick, scheme
1. 18 U.S.C. § 1001 authorizes criminal pen altiesaganand willfully falsifies,
conceals orividual who, in antcovers �up bylany tric n of any
department or agency of the United States , knowingly statements or
or device a material fact, or makes any false, fictitious falser fictitious alent or fraudulent representations,
e statemor ent r makes any fa se
writing or document knowing the same to containY
Individual offenders are subject to fines of up t357150' Sect on 35 imprisonment000 and 1(d) soauthor zes fines of up to twice thetgarossr gain organizations
by the
subject to fines of up to $500,000 (18 U.S.C. § )
offender if it is greater than the amount specifically authorized by the sentencing statute.
statement or representation of a material fact in any application for any
2. Section 1128B(a)(1) of the Social Security Act a stat authorizes criminal penalties against any individual who, "knowingly an
willfully," makes or causes to be made any fats
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. person who:
3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any p
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, o
- 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. person (including an organization,
4. Section 1128A(a)(1) of the Social Security Act imposes civil liability'in part, on presented to an officer, employee, or agent of the
agency or other entity) that knowingly presents or causes .to bebState agency...a claim...that the Secretary determines
United States, or of any department or agency thereof, or of any
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. 000 for each item or service, an to three times the
This provision authorizes a civil monetary penalty
in the Medicare program and S10, ta a health care programs.rnent of up
amount claimed, and exclusion from participation aid b mistake,° and "unjust
5. The government may assert common law claims such as ,common law fraud," "money p Y
enrichment."
m and unitive dama es, restitution, and recove of the amount of the unjust profit. CMS 855B (11/2001)
Remedies include coensato
37
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 ❑ if this supplier will not be assigning any delegated official(s) and skip to Section 17.
B. Delegated Official Signature El Add ❑ Delete ❑ 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.)
Signature
Date (MM/DD/YYYY)
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
❑Copy(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
45 CMS 855B (11/2001)
OMB Approval No. 0938-0685
15. Certicatioln`Staternent
in
at must
e met
This section is used to officially notify the supplier of additional requirements also
l eontretuies thebsignatu a and/ date ethereo order of an
the supplier to be enrolled in the Medicare program. This se ctto the laws, regulations, and program instructions of
"Authorized Official" who can legally and financially bind the suppliersupplier's enrollment
the Medicare program. Section 16 permits the fou�her1Zurposeed coflreporting futuregchangesuto the supplier individuals
(Delegated Officials) employed by the supplier P
record. See instructions to determine who ualifies as an Authorized Official and a Dele ated Official for the su lier.
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:
ed in this form ays
1.) I agree to notify the Medicare contractor of any future changes to the understand that any change in the ness structure uctu a of this supplierormation contain
itmia 9 equ re
of the effective date of the change. I and
the submission of a new application.
application or contained in
2.) I have read and understand the Penalties
or falsification of any ition, as printed in nformat on contained n application.
I understanda any
deliberate omission, supplying
information
application form,
any communication supplying information to Medicare, or any deliberate alteration of any text on this app
may be punished by criminal, civil, or administrativefines,civildamages and/or mpnsonmeut not lnmited to, the revocation of Medicare
billing number(s), and/or the imposition of t. to this supplier. The Medicare
3.) 1 agree to abide by the Medicare laws, regulations and program instructions that apply with such laws,
laws, regulations, and program instructions available throand She hu Medi ng transactioon understand that payment
complying
care co
of a claim by Medicare is conditioned upon the
claimregulations, and program instructions (incaudl able Condit olns of participation ted to, the in Medicare.
statute and the Stark law),
and on the supplier's compliance with all pp, officer, director, em to ee, authorized
4.) Neither this suppli, onor any 5% or greater owner, fficial thereof is currently sanctioned, ed,artr suspended, debarred or
aexcluded by the Medicare or
official, or delegated
Medicaid program, or any other Federal program, or is otherwise prohibited from supplying services to Medicare or
other Federal program beneficiaries. lier b the Medicare program may be recouped by
5.) 1 agree that any existing or future overpayment made to the supp Y
Medicare through the withholding of future payments.
6.) 1 will not knowingly present or cause to be presented
d regard of their t lentuth claim for payment by Medicare, and will no
e
submit claims with deliberate ignorance or re Delete ❑Change Effective Date:
B. Authorized Official Signature Add ❑ lier to the laws,
I have read the contents of this application. My signature legally and financially binds this that the information
regulations, and program instructions of the Medicare program. By my know ledgenature, I certify, I authorize the Medicare program
contained herein is true, correct, and complete, to the best of my g ' application is not true, correct,
contractor to verify this information. If I become aware that any information in this
or complete. I aaree to notifv the Medicare oroaram contractor of it fact immediately. Jr Sr., etc.
First Middle
Authorized Official Name Charles McCoy
Print Date MMIDD/YYYY)
Title/Position
Authorized Official (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Mayor Signed
Signature
APPROVED AS TO FO
AND AL SUFF! Y.
Y.
A.N� E HU TON
D'?- _______%��10Z-
CMS 855B (11/2001)
41