HomeMy WebLinkAbout20022781.tiff RESOLUTION
RE: APPROVE TWO APPLICATIONS FOR CHANGE OF INFORMATION AND INITIAL
ENROLLMENT FOR MEDICARE PROVIDER AND AUTHORIZE CHAIR TO SIGN
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board has been presented with two Applications for Change of
Information and Initial Enrollment for Medicare Provider from the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Weld County Department of Public Health and Environment, to the U.S. Department of Health
and Human Services, with terms and conditions being as stated in said applications, and
WHEREAS, after review, the Board deems it advisable to approve said applications,
copies of which are attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, that the two Applications for Change of Information and Initial
Enrollment for Medicare Provider from the County of Weld, State of Colorado, by and through
the Board of County Commissioners of Weld County, on behalf of the Weld County Department
of Public Health and Environment, and the U.S. Department of Health and Human Services be,
and hereby are, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said applications.
The above and foregoing Resolution was, on motion duly made and seconded, adopted
by the following vote on the 16th day of October, A.D., 2002.
BOARD OF COUNTY COMMISSIONERS
WELD COUNTY, COLORADO
ATTEST: I ®/) t o m EXCUSED
6i ►�/�� ,� �� c-, Vaad, Chair
Weld County Clerk tot o , °
:Y,,.
Ad ��
�t Davi. E. ong, Pro-Te
BY: Ce / _
°� �Deputy Clerk to the ��
M. J. eile
APPR ED A ORM: `-cti
Wiliam H. Jerke%Dr--
ti r Attorney �' �.c >
/o/c Robert D. Masden
Date of signature:
e. , A✓4 2002-2781
HL0029
rit ‘t- Memorandum
TO: Carol Harding, Office of
Clerk to the Board
•
COLORADO FROM: Judy Nero, Dept. oublic Health and
Environment
DATE: October 11, 2002
SUBJECT: Application for Change of Information and
Initial Application for Medicare Provider
Enclosed are two packets of information the WCDPHE is submitting to Medicare. One packet is
to change our name and address to our current location. We had previously written a letter to
Medicare to make these changes effective May 3, 1999 when we moved and changed the name
from Health Department to Department of Public Health and Environment. Apparently,
Medicare either did not receive the letter or did not process the changes. The second packet is
for an initial enrollment application. When we called regarding changing the address, Medicare
instructed us to also complete an initial application as they did not have one on file.
As we discussed earlier today in a phone conversation, we did not complete section 16 to appoint
Dr. Mark Wallace as a delegated official since you feel we will not have to submit a change
every January when the Chair of the Board of County Commissioners changes. If after
reviewing the document you believe we should ask the Commissioners to do this, please let me
know and we will complete this section and submit it for BOCC approval and signature.
Please obtain the appropriate signatures on these two applications and return them to me. We
will then submit them to Medicare. Thank you very much for your assistance in processing these
documents.
Enc.
2002-2781
MEDICARE
FEDERAL HEALTH CARE
PROVIDER/SUPPLIER ENROLLMENT APPLICATION
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Application for Health Care
Suppliers that will Bill
Medicare Carriers
CENTERS FOR MEDICARE & MEDICAID SERVICES
CMS 855B(11/2001)
(Formerly HCFA 855)
OMB Approval No. 0938-0685
C ENTERS FOR Medicare
M EDICARE & MEDICAID Provider/Supplier
S ERVICES Enrollment Application
Privacy Act Statemett
he Centers for Medicare and Medicaid Services(CMS) is authorized to collect the information requested on this form by sections
124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42 U.S.C. §§ 1320a-3(a)(1), 1320a-7, 1395f,
395g, 1395(1)(e), and 1395u(r)] and section 31001(1) of the Debt Collection Improvement Act [31 U.S.C. § 770I(c)].
he purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in the Medicare
rogram as providers/suppliers of goods and services to Medicare beneficiaries and to assist in the administration of the Medicare program.
his information will also be used to ensure that no payments will be made to providers or suppliers who are excluded from participation in
he Medicare program. All information on this form is required, with the exception of those sections marked as"optional" on the form.
ithout this information, the ability to make payments will be delayed or denied.
he information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS), and either system number
9-70-0525 titled Unique Physician/Practitioner Identification Number(UPIN) System (published in Vol. 61 of the Federal Register at page
0,528 (May 7, 1996)), or the National Provider Identifier(NPI) System, Office of Management and Budget(OMB) approval 0938-0684 (R-
87). The information in this application will be disclosed according to the routine uses described below.
nformation from these systems may be disclosed under specific circumstances to:
CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
A congressional office from the record of an individual health care provider/supplier in response to an inquiry from the congressional
ffice at the written request of that individual health care practitioner;
The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
Peer Review Organizations in connection with the review of claims, or in connection with studies or other review activities, conducted
ursuant to Part B of Title XVIII of the Social Security Act;
To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States Government is a party
o litigation and the use of the information is compatible with the purpose for which the agency collected the information;
To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which criminal penalties are
ttached;
To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique Physician
dentification Number Registry is unable to establish identity after matching contractor submitted data to the data extract provided by the
MA;
An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or to
he restoration or maintenance of health;
Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers/suppliers of medical services/
upplies or to detect fraud or abuse;
0) State Licensing Boards for review of unethical practices or non-professional conduct;
1) States for the purpose of administration of health care programs; and/or
2) Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care groups providing
ealth care claims processing, when a link to Medicare or Medicaid claims is established, and data are used solely to process provider's/
upplier's health care claims.
he enrolling provider or supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) amended
he Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through computer matching.
Protection of Proprietary Information
rivileged or confidential commercial or financial information collected in this form is protected from public disclosure by Federal law 5
.S.C. § 552(b)(4)and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal
f any information within this application (or attachments thereto) constitutes a trade secret or privileged or confidential information (as such
erms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal nature such that
isclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then such information will be
rotected from release by CMS under 5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.
2 CMS 855B(11/2001)
OMB Approval No. 0938-0685
INSTRUCTIONS FOR HEALTH CARE SUPPLIERS
THAT WILL BILL MEDICARE CARRIERS
lease PRINT or TYPE all information so it is legible. Do not use pencil. Failure to provide all requested information may
ause the application to be returned and may delay the enrollment process. Certain sections of the application have been
mitted because they do not apply to suppliers. See inside front cover for mailing instructions. Electronic copies of all CMS
Medicare enrollment forms can be found at the Medicare web-site at(http://www.hcfa.gov/medicare/enrollment/forms/).
hese electronic forms may be downloaded to your computer, completed on screen, printed, signed, and mailed to the
ppropriate Medicare contractor.
Whenever additional information needs to be reported within a section, copy and complete that section for each additional
ntry. We strongly suggest maintaining a photocopy of this completed application and supporting documents for future
eference.
his application is to be completed by all suppliers that will bill Medicare carriers for medical services provided to Medicare
eneficiaries. Failure to promptly submit a completed CMS 855B to the carrier will result in delays in obtaining enrollment
nd billing privileges.
his form is also used to enroll physician(s), non-physician practitioner(s)and other health care providers/suppliers who form
practice together and bill Medicare as a single supplier. This includes individuals, partnerships, groups, organizations and
orporations, hereafter referred to as "organizations." An individual whose business is incorporated, has received a tax
dentification number for the business, and receives Medicare payment in the name of the business would qualify as an
rganization. Partnership agreements may be requested by the carrier on an "as needed" basis to determine if the partnership
meets State requirements. If a supplier has individual practitioners, each member of the supplier must receive his or her own
nique Physician Identification Number(UPIN) and enroll as an individual (using the Application for Individual Health Care
ractitioners, CMS 855I). Once the individual practitioner is enrolled, he/she can enroll as a member of an organization.
When joining an organization every member of the organization must complete a copy of the CMS 855R(Individual
eassignment of Benefits).
fter completing this enrollment application,the supplier may wish to submit additional forms in the following situations:
To accept assignment of the Medicare Part B payment for all services the supplier renders, the organization should
omplete the form "Medicare Participating Physician or Supplier Agreement" (Form HCFA-460).
To have Medicare payments sent electronically to a supplier's bank account, the supplier should complete the form
Medicare Authorization Agreement for Electronic Funds Transfers" (Form HCFA-588).
To submit claims electronically,the supplier should complete the Electronic Data Interchange (EDI)agreement.
f the supplier plans to do any of the above, submit the appropriate form(s)/agreement(s)with this application. The forms
hould have been received with this initial enrollment package. If not, they can be obtained from the Medicare carrier.
o reduce the burden of furnishing certain types of supporting documentation, we have designated specific types of
ocumentation to be furnished on an "as needed" basis. However, the carrier may request, at any time during the enrollment
rocess, documentation to support or validate information that is reported in this application. Some examples of documents
hat may be requested for validation purposes are billing agreements, IRS W-2s, pay stubs, articles of incorporation, and
artnership agreements.
HOW TO MAKE CHANGES OR UPDATES TO A PREVIOUS APPLICATION
f a supplier changes its tax identification number(TIN), a new enrollment application must be completed, even if most of the
ata on the form remains the same unless the TIN is the only information that is changing(see "Change of Information"
nstructions on page 5). This change will also require that each individual in the newly enrolled supplier submit an updated
MS 855R to reassign his or her benefits to the new supplier. If an existing supplier changes its name/ownership/address,
tc., and there is no change in its tax identification number, the supplier must annotate the change by checking the section
here the change is going to be made, and must sign and date the certification statement. For example, if an existing supplier
s only adding a practice location and has previously completed an application,the supplier completes Sections 1, 4, and 15.
he supplier does not complete a full application. If the supplier is adding or deleting a member who currently is reassigning
is/her benefits to the supplier, it only needs to complete a CMS 855R to make such a change. The member may also delete
is/her reassignment of benefits by completing and submitting the CMS 855R.
3 CMS 855B(11/2001)
OMB Approval No. 0938-0685
DEFINITIONS OF MEDICARE ENROLLMENT TERMINOLOGY
o help you understand certain terms used throughout the application,we have included the following definitions.
Authorized OfficialAn appointed official to whom the supplier has granted the legal authority to enroll it in the Medicare
rogram,to make changes and/or updates to the supplier's status in the Medicare program (e.g., new practice locations,
hange of address,etc.)and to commit the supplier to fully abide by the laws,regulations,and program instructions of
Medicare. The authorized official must be the supplier's general partner, chairman of the board,chief financial officer, chief
xecutive officer,president,direct owner of 5%or more of the supplier(see Section 5 for the definition of a("direct owner"),
r must hold a position of similar status and authority within the supplier organization.
illing Agency-A company that the enrolling supplier contracts with to furnish claims processing functions for the supplier.
Carrier-The Part B Medicare claims processing contractor.
Delegated Official-Any individual who has been delegated,by the supplier's "Authorized Official,"the authority to report
hanges and updates to the supplier's enrollment record.A delegated official must be a managing employee(W-2)of the
upplier or have a 5%ownership interest,or any partnership interest, in the supplier.
iscal Intermediary-The Part A Medicare claims processing contractor.
evil Business Name-The name that is reported to the Internal Revenue Service (IRS)for tax reporting purposes.
Medicare Identification Number-This is a generic term for any number that uniquely identifies the enrolling supplier.
xamples of Medicare identification numbers are Unique Physician/Practitioner Identification Number(UPIN), Online
urvey Certification and Reporting number(OSCAR), and National Supplier Clearinghouse(number) (NSC).
Mobile Facility/Portable UnitThese terms apply when a service that requires medical equipment is provided in a vehicle,or
he equipment for the service is transported to multiple locations within a geographic area. The most common types of mobile
acilities/portable units are mobile IDTFs,portable X-ray, portable mammography, and mobile clinics. Physical therapists
nd other medical practitioners(e.g.,physicians,nurse practitioners,physician assistants)who perform services at multiple
ocations(i.e., house calls,assisted living facilities)are not considered to be mobile facilities/portable units.
rovider-A provider is a hospital,critical access hospital, skilled nursing facility, nursing facility,comprehensive outpatient
ehabilitation facility, home health agency,or hospice,that has in effect an agreement to participate in Medicare;or a rural
ealth clinic (RHC), Federally qualified health center(FQHC), rehabilitation agency,or public health agency that has in
ffect a similar agreement but only to furnish outpatient physical therapy or speech pathology services;or a community
mental health center that has in effect a similar agreement but only to furnish partial hospitalization services. A provider is not
ynonymous with the corporation or other legal entity that owns or operates the provider. The "provider" is the CMS
ecognized provider type listed above. Therefore, an owning or operating entity may own or operate many providers.
rovider Identification Number(PIN)-This number is assigned to providers, suppliers,groups and organizations in
Medicare Part B. This number will identify who provided the service to the beneficiary on the Medicare claim form.
upplier-A physician or other practitioner,or an organization other than a provider that furnishes health care services under
Medicare Part B. The term supplier also includes independent laboratories,portable x-ray services,physical therapists in
rivate practice,end stage renal disease(ESRD) facilities,and chiropractors. For enrollment purposes,suppliers that submit
laims for durable medical equipment,prosthetics,orthotics, or supplies(DMEPOS)must complete the CMS 855S. This
pplication(CMS 855B) is not for DMEPOS suppliers.
ax Identification Number(TIN)-This is a number issued by the Internal Revenue Service(IRS)that the supplier uses to
eport tax information to the IRS.
Unique Physician/Practitioner Identification Number(UPIN)This number is assigned to physicians,non-physician
ractitioners,and suppliers to identify the referring or ordering physician on Medicare claims.
4 CMS 855B(11/2001)
OMB Approval No. 0938-0685
-7717 � �� eNTE a'MAY ON
m t jA}
General Instructions
The Medicare Federal Health Care Provider/Supplier Enrollment Application has been designed by the Centers for
Medicare and 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 (x)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.
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: O Initial Enrollment Reactivation
® Change of Information (Check appropriate Section(s) below and furnish this
supplier's Medicare Identification Number here): 30496
• 1 ® 2 ❑ 3 ® 4 ® 5 06 08 ❑ 9 ❑ 10 0 1 ® 15 0 1
Attachment 1- ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 Attachment 2- ❑ 1 ❑ 2 ❑ 3 ❑ 4
0 Voluntary Termination of Billing Number-- Effective Date: / /
❑ Change of Ownership(Hospitals, Portable X-Ray Facilities,and
Ambulatory Surgical Centers)- Only
2. Tax Identification Number. 844000-813
3. Is this supplier currently enrolled in the Medicare program? ® YES ❑ NO
IF YES, furnish the following information about the current carrier.
NORIDIAN 30496
Current Carrier Name:
Current Medicare Identification Number:
5 CMS 855B(11/2001)
OMB Approval No. 0938-0685
"• •• t h h3 nr h ;•
".
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 O Change Effective Date: r
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)
❑ Ambulance Service Supplier 0 Multi-Specialty Clinic or Group Practice
❑ Ambulatory Surgical Center 0 Occupational Therapy Group(complete#2 below)
❑ Diagnostic Radiology Group Practice/Clinic ❑ Other Medical Care Group
❑ Hospital Department(s), Hospital Outpatient Location(s) ❑ Physical Therapy Group(complete#2 below)
and/or Hospital Clinic(s) (complete#4 below)
❑ Physiotherapy Group
❑ Independent Clinical Laboratory(CLIA) ❑ Portable X-ray Facility
❑ Independent Diagnostic Testing Facility(IDTF) ® Public Health/Welfare Agency
❑ Mammography Screening Center 0 Voluntary Health/Charitable Agency
❑ Managed Care Plan (non-Medicare+Choice) ❑ *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 0 NO
d) Is this private office space used exclusively for the group's private practice? 0 YES 0 NO
e) Does this group furnish PT/OT services outside of its office and/or patients'homes? 0 YES 0 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 11g Change Effective Date: 05/03/1990
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/YYY)
WELD COUNTY GOVERNMENT 07/02/1975
2. "Doing Business As" (DBA) Name(if applicable) County/Parish where DBA Name Registered
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH&ENVIRONMEN (if applicable )
3. Identify the type of organizational structure for this supplier(Check one): COUNTY GOVERNMENT
❑ Corporation ❑ Partnership ® Other(Specify):
4. Incorporation Date(if applicable)(MM/DD/YYY) State where
/ / Incorporated(if
6 CMS 855B(11/2001)
OMB Approval No. 0938-0685
I '
C. Correspondence Address ® Change Effective Date: 05/03/1999
This must be an address and telephone number where Medicare can contact this supplier directly.
Mailing Address Line 1 1555 N. 17THAVE.
Mailing Address Line 2
City GREELEY State CO ZIP Code+4 80631-9117
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address(if applicable)
(970)304-6410 ( (970)304-6412
D. Accreditation (Ambulatory Surgical Centers (ASCs) ONLY) 0 Change Effective Date: / /
1. Is this supplier accredited?
0 YES ❑ NO
IF YES, complete the following: / / 0 PENDING
2. Date of Accreditation (MM/DD/YYY):
3. Name of Accrediting Body:
E. Comments
Explain any unique or unusual circumstances conceming the supplier's practice location(s), the method by which the supplier
renders health care services, or any special billing number requirements.
7 CMS 855B(11/2001)
OMB Approval No. 0938-0685
efts
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 11 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 Z 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
1. Does this supplier, under any current or former name or business identity, have any outstanding
Medtflmayments? ❑ 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:
8 CMS 855B(11/2001)
OMB Approval No. 0938-0685
4, c rrsVFbdbt+ detataati*ln(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 9 Add 9 Delete ® Change Effective Date: 05/03/1999
1. Practice Location Name WELD COUNTY DEPT OF PUBLIC HLTH 8 ENVIR Date Started at this Location
(MM/DD/YYYY) 05/03/1999
2. Practice Location Address Line 1 1555 N. 17TH AVENUE
Practice Location Address Line 2
City GREELEY County/ WELD State CO ZIP Code+ 4 806314117
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
(970)304-6410 ( ) (970)304-6412
3. Does this supplier own/lease this practice location? 0 YES ❑ NO
4. Is this practice location a: hospital? ❑ YES ❑ NO
retirement/assisted living community? 9 YES 9 NO
group practice office/clinic PUBLIC HEALTH DEPARTMENT ❑ YES ❑ NO
other health care facility? (Specify): ® YES 9 NO
5. CLIA Number for this location Of applicable) FDA/Radiology(Mammography)Certification Number(s)for this
06D0665967 06D0688511 location (if applicable)
B. Mobile Facility and/or Portable Units 9 Change Effective Date:
Does this supplier furnish health care services from a mobile facility or portable unit? ® YES 9 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 9 Add 9 Delete ® Change Effective Date: 05/03/1999
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 0 and skip to Section 4D if the"Base of Operations"address is the same as the"Practice Location."
1. Base of Operations 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 9 Add 9 Delete 9 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
NA NA
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.
9 CMS 855B(11/2001)
OMB Approval No. 0938-0685
4. P+a tie4-4.csta#ildf46oindirihed)
E. Geographic Location where the Base of Operations and/or Vehicle Renders Services
❑ Add 9 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 Z Change Effective Date: 05/03/1999
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
1 5 N.17TH AVENUE
"Pay To"Address Line 2
CiyEELEV State CO zea9i19+ 4 - -
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 9 Change Effective Date: 02/01/2002
1. Check here O if all patients'medical records are stored at the location shown in Section 4A or 4C, and skip this section.
2. If any 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
WELD COUNTYDEPARTMENT OFPUBLIC HEALTH AND ENVIRONMENT SOUTHWEST SITE
Storage Facility Address Line 1
4209 WCR 241/2
Storage Facility Address Line 2
City r e__—
State p n _ - -_-_-- -
LONGMONT CO �0507� 3 +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.
10 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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 n if this section does not apply and skip to Section 6.
B. Organization with Ownership Interest and/or Managing Control-Identification Information
O Add ❑ Delete ® Change Effective Date: 05/03/1999
1. Check all that apply: ❑ 5%or more Ownership Interest Effective Date of Ownership
® Managing Control O Partner (MM/DD/YYYY) /
2. Legal Business Name Effective Date of Control
WELD COUNTY GOVERNMENT (MM/DD/YYYY) 0//02/1975
3. "Doing Business As" Name(if applicable)PUBLIC HEALTH AND ENVIRONMENT T84-6c000-8113tion Number
WELD COUNTY DEPARTMENT OF
41555 N 17TAAAVI NUE e 1 Medicare Identification Number(s)
(if applicable)
Business Address Line 2
CitGsy REELEY State CO ZIP Code+ 4
80831-9117
C. Adverse Legal History 0 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? 0 YES 0 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:
11 CMS 855B(11/2001)
OMB Approval No. 0938-0685
6' Wt�._x _' �. GtlottrYii�t}Yal
This section is to be completed with information about any individual that has a 5% or greater(direct or indirect)ownership
interest in, or y 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 O Delete O 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) 10/09/2002 (MM/DD/ / /
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 0 Other(Specify)
3. If the above individual is directly associated with an organization identified in Section 5B,fumish 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 0 Other(Specify)
B. Adverse Legal History O 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? 0 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:
12 CMS 855B(11/2001)
OMB Approval No. 0938-0685
fr t n . Bieorsome ticabb
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 m. if this section does not apply and skip to Section 9.
B. Billing Agency Name and Address ❑ Add ❑ Delete 0 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.) Fa )
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 0 NO
2. Does the supplier's Medicare payment go directly to the supplier? ❑ YES 0 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? 0 YES 0 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? 0 YES 0 NO
b) Does the supplier have unrestricted access to the bank account and statements? ❑ YES 0 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 0 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 0 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
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? 0 YES 0 NO
5. Who receives the supplier's Medicare payment?
13 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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 EI if enrolling in Medicare for the first time and would like to submit claims electronically.
C. 1st Clearinghouse Name and Address ❑ Add ❑ Delete ❑ Change Effective Date: i
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: r '
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
T le phone Number (Ex�) Fax Number(if applicable) E-mail address (if applicable)
14 CMS 855B(11/2001)
OMB Approval No. 0938-0685
10. StaffingComPagY
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 i5, 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 (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? [l Not applicable YES ❑ NO
D. 2nd Staffing Company using this Supplier-Name and Address
E 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 (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
{ ) - t ) ( ) -
E. 2nd 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)? [j 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 L._] NO
15 CMS 8S5B(11/2001)
OMB Approval No. 0938-0685
7,ll lltr<.l s 1. a tiQtt Not AQ
a r. a a .. a o y '. "". . t. . .. :: . ._ x _. > Q ::: u. . ..:::�tl i9` ,t_
i..h„ , ,el;. a.t� E_ v .r i.t ..,, to i"7°�..ri`'�'.:. 1., I " �.i+ ,' .._ .: " �tT(t. { , •....... .. '.k: �,.
Furnish the name(s)and telephone number(s)of a person(s)who can answer questions about the information fumished 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 Rif this section does not apply and skip to Section 14.
B. 1st Contact Name and Telephone Number ® Add 0 Delete ❑ Change Effective Date: 10/0002002
Name First Last E-mail Address Of applicable applicablej Telephone Number (Ext.)
WENDY PARIS WPARIS@CO.WELD.CO.US (970)304-6410 (2116)
C. 2nd Contact Name and Telephone Number ® Add O Delete ❑ Change Effective Date: / /
Name First Last E-mail Address (if applicable) Telephone Number (Ext.)
JUDY NERO JNERO@CO.WELD.CO.US (970)304-6410 (2122)
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,
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
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 gaiderived by
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
16 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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 suppliers 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
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 suppliers 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 0 Add Delete 0 Change Effective Date: 05/03/1999
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 I authorize 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 agree
to notify the Medicare program contractor of this fact immediately.
Authorized Official Name
First Middle Last Jr., Sr., etc.
Print Glenn Vaad
Authorized Offici 1 (F' t, 1ddle, Last, Jr., Sr., M.D., D.O., etc.) ITitle/Position Date(MM/DDYYY)
Signature Slag
4 4+ j /YChair, Weld Signed 10/16/02
-� County Board of Commissioners
17 CMS 855B(11/2001)
OMB Approval No. 0938-0685
n
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 suppliers 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
A. Check here M if this supplier will not be assigning any delegated official(s)and skip to Section 17.
B. Delegated Official Signature ❑ Add ❑ Delete ❑ Change Effective Date: f /
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 r 1 f
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
3i,. :. , R n.... .. ,big,h.g.
�! .�,.(✓� ��57!ilEk5dl�3..,., ., e ua, d�ti ,d.. },{.�p,9k.!��„,. Sri:.�'. ,.L. ., ;',...,. ., .....
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)
0 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
0 Completed Form HCFA-588-Authorization Agreement for Electronic Funds Transfer
0 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
18 CMS 855B(11/2001)
OMB Approval No. 0938-0685
ATTACHMENT 1
A[ e¢ 13� �a��ppliers
This attachment is to be completed by all ambulance service suppliers enrolling in the Medicare program.
1111
This section is to be completed with information about the geographic area in which this company furnishes ambulance services.
When applicable, State license information must be provided. In addition, a copy of the current State license must be
submitted with this application.
A. Geographic Service Area ;J Add ❑ Delete Effective Date:
Furnish the county/parish,city, State and ZIP Code for all locations where this ambulance company renders service.
Note: If this ambulance company renders services in more than one State,and those States are serviced 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):
B. State License Information 1 Add Li Delete Change Effective Date:
1. Is this ambulance company licensed in the State where services are rendered and billed for'? fl YES [] NO
2. IF NO, explain why:
3. IF YES, furnish the license information for the State where this ambulance service supplier will be rendering services
and billing Medicare. Attach a copy of the current State license.
License Number Issuing State(if Issuing County/Parish (if applicable)
applicable)
Effective Date(MM/DD/YYYY) Expiration Date(MM/DD/YYYY)
19 CMS 855B (11/2001)
OMB Approval No. 0938-0685
L OIpiQfehicte
This section is to be completed with information about the vehicles used by this ambulance company, the equipment they
carry, and the services they provide. If there are more than two vehicles, copy and complete this section as needed. A
copy of each vehicle's registration MUST be submitted. For air ambulance suppliers, attach a copy of FAA 135.
A. 1st Vehicle Information ❑ Add HI Delete LIChange Effective Date:
1. Type(automobile, aircraft, boat, etc.) Vehicle Identification Number
Make Model Year(YYYY)
2. Does this vehicle have the following:
first aid supplies? ❑ YES ❑ NO other safety/life-saving equipment? [ I, YES -a NO
oxygen equipment? ❑ YES ❑ NO two-way telecommunications radio? 7 YES ❑ NO
emergency warning lights? Li YES ❑ NO mobile communication/wireless telephone? ❑ YES ❑ NO
sirens? ❑ YES ❑ NO stretcher? 1 i YES ❑ NO
clean linens? ❑ YES ❑ NO
Report other medical equipment this vehicle carries:
3. Does this vehicle provide:
basic life support(BLS)? ❑ YES ❑ NO land ambulance? ❑ YES ❑ NO
advanced life support(ALS)? ❑ YES ❑ NO air ambulance? [ YES ❑ NO
emergency runs? ❑ YES ❑ NO marine ambulance? [ ' YES ❑ NO
non-emergency runs? ❑ YES r1 NO
How many crewmembers accompany this vehicle on runs?
B. 2nd Vehicle Information j ; Add __ Delete Change Effective Date:
1. Type (automobile, aircraft, boat, etc.) Vehicle Identification Number
Make Model Year(YYYY)
2. Does this vehicle have the following:
first aid supplies? [] YES ❑ NO other safety/life-saving equipment? ❑ YES 7 NO
oxygen equipment? ❑ YES ❑ NO two-way telecommunications radio? r] YES NO
emergency warning lights? ❑ YES ❑ NO mobile communication/wireless telephone? ❑ YES NO
sirens? ❑ YES ❑ NO stretcher? Li YES [J NO
clean linens? ❑ YES ❑ NO
Report other medical equipment this vehicle carries:
3. Does this vehicle provide:
basic life support(BLS)? ❑ YES ❑ NO land ambulance? ❑ YES TA NO
advanced life support(ALS)? ❑ YES ❑ NO air ambulance? ❑ YES 0 NO
emergency runs? [_l, YES [ 1 NO marine ambulance? O YES ❑ NO
non-emergency runs? [_i YES Li NO
How many crewmembers accompany this vehicle on runs?
20 CMS 855B(11/2001)
OMB Approval No. 0938-0685
1 i 4
to
This section is to be completed with information about all crewmembers. In addition to the identifying information, all health care
related training courses completed by the crewmember must be reported(see CFR 410.40 and CFR 410.41). If there are more
than five crewmembers, copy and complete this section as needed.
A. 1st Crewmwmember Information ❑ Add ❑ Delete 9 Change Effective Date:
1. Name First I Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY)
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
B. 2nd Crewmember Information ❑ Add 0 Delete ❑ Change Effective Date: / /
1. Name First Middle Last Jr., Sr., etc.,
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
C. 3rd Crewmember Information 9 Add 9 Delete ❑ Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.,
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.) and attach copy(s)of training certificate(s).
D. 4th Crewmember Information 9 Add 0 Delete O Change Effective Date:
1. Name First I Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
E. 5th Crewmember Information ❑ Add 0 Delete ❑ Change Effective Date:
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY)
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
21 CMS 855B(11/2001)
OMB Approval No. 0938-0685
This section is to be completed with specific information about the ambulance service supplier if it only furnishes Certified Basic
Life Support(BLS)services.
A. Check here 6a if this section does not apply and skip to Section 5.
B. Paramedic Intercept Services Information 0 Change Effective Date:
Does this company have a contract with a paramedic or Emergency Medical Technician (EMT)organization or other Advanced
Life Support(ALS)ambulance supplier whereby the Paramedic/EMT organization or other ALS supplier furnishes Paramedic
Intercept Services? 0 YES ® NO
IF YES, submit a copy of the signed contractual agreement(s).
gice
tlu3 iI3' l2� t3 3 .a , ¢`. 1
Id ii; .. n. '_i.. .. • i, , t 'iYesPALLlea?I3ttdall JIRI
This section is to be completed with specific information about the ambulance service supplier if the company furnishes Certified
Advance Life Support(ALS)services.
A. Check here ® f this section does not apply and skip to Section 6.
B. Certified Advanced Life Support Questionnaire ❑ Change Effective Date: /
1. Is this company certified to perform defibrillation? ❑ YES ❑ NO
IF YES, attach a copy of the certification.
2. Does this company have a contract with a Basic Life Support Service, such as a volunteer ambulance company,
whereby the ALS supplier fumishes Paramedic Intercept Services? 0 YES 0 NO
IF YES, submit a copy(s)of the signed contractual agreement(s).
This section is to be completed with information about all Medical Directors associated with this ambulance service supplier.
Some States require ambulance companies to have a Medical Director on staff as a requirement for State licensing. If your
State has such a requirement, this section must be completed. If this ambulance company has more than one Medical
director, copy and complete this section for each.
A. Check here Z if a Medical Director is not required by the State where this ambulance company renders
and skip this section.
B. Medical Director Identification 9 Add 9 Delete 9 Change Effective Date: / /
Medical Director First Name Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
22 CMS 855B(11/2001)
OMB Approval No. 0938-0685
ATTACHMENT 2
. P { S iq. id t YlY lnr 0 I “, a I i „-11 oI
C[
This attachment is to be completed by all Independent Diagnostic Testing Facilities enrolling in the Medicare program. See
instructions to determine if this supplier needs to complete this Attachment to enroll in Medicare as an IDTF.
'I -d�A. a.-. CaJLll a IartaligaiPPSIFIERiiniilinlYINPRiMariali
! .. ,1�i AIA :.,.. ii di I IhIbiI I IPin ,..,. ., , .... .₹
This section is to be completed with information about this IDTF's compliance with current CMS IDTF standards,the types of tests
performed by this IDTF, and the equipment used by this I DTF.
A. Standards Qualifications
Does this Independent Diagnostic Testing Facility meet all current CMS standards for IDTFs? ❑ YES O NO
IF YES, furnish the date that all standards were met:
O
B. CPT-4 and HCPCS Codes ❑ AddDelete Effective Date: ` i
Furnish all Current Procedural Terminology,Version 4(CPT-4)codes or HCFA Common Procedure Coding System codes
(HCPCS)for which this IDTF intends to bill Medicare. In addition, report all equipment this IDTF will be using and the model
number of each piece of equipment.
CPT-4 or HCPCS Code Equipment Model Number
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
23 CMS 855B(11/2001)
OMB Approval No. 0938-0685
2. n.X armation
This section is to be completed with identifying information about all physicians whose interpretations will be billed by this IDTF.
If there are more than eight physicians, copy and complete this section as needed.
A. Check here L if this section does not apply and skip to Section 3 of this Attachment.
B. 1st Interpreting Physician Information 7; Add fl Delete [_:J Change Effective Date: '
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
C. 2nd Interpreting Physician Information Li Add lJ Delete ❑ Change Effective Date:
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
D. 3rd Interpreting Physician Information Add ❑ Delete [1, Change Effective Date: ' '
Name First Middle Last Jr., Sr., etc.
Social Security Number 1Date of Birth (MM/DD/YYYY) Medicare Identification Number
- - I
i
E. 4th Interpreting Physician Information El Add [,_1 Delete E Change Effective Date: •
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
- - / l
F. 5th Interpreting Physician Information [] Add -' Delete ; _] Change Effective Date:
Name First Middle Last Jr., Sr., etc.
r
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
G. 6th Interpreting Physician Information ri J Add P Delete ❑ Change Effective Date:
Name First ' Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
- Ii
H. 7th Interpreting Physician Information Cl Add .___ii Delete ❑ Change Effective Date:
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
/ `
I. 8th Interpreting Physician Information I I Add _J Delete ( ] Change Effective Date:
Name First Middle Last Jr., Sr., etc.
I
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
- -
Note: All interpeting physicians must be currently enrolled in the Medicare Program.
24 CMS 855B(11/2001)
OMB Approval No. 0938-0685
nsF!` iftgiftlion
This section is to be completed with information about all non-physician personnel who perform tests for this I DTF.If there
are more than six technicians, copy and complete this section as needed.
A. 1st Non-Physician Personnel Information `] Add f Delete u Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? ❑ YES ❑ NO
License/Certification Number(if applicable) License/Certification Issue Date/(if applicable)
(MM/DD/YYYY)
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? ❑ YES ❑ NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? H YES ❑ NO
IF YES, furnish the name of the hospital here: _
B. 2nd Non-Physician Personnel Information ( I Add __] Delete i__1 Change Effective Date:
1. Name First Middle 'Last I Jr., Sr., etc. .
Social Security Number Date of Birth (MM/DD/YYYY) /
2. Is this technician State licensed or State certified? ❑ YES [] NO
License/Certification Number(if applicable) j License/Certification Issue Date(if applicable)
(MM/DD/YYYY)
State of Issuance (if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? I ) YES H NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES ❑ NO
IF YES, furnish the name of the hospital here: _
C. 3rd Non-Physician Personnel Information H Add r_; Delete ';! Change Effective Date:
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY)
_ _ / /
2. Is this technician State licensed or State certified? ❑ YES ❑ NO
License/Certification Number(if applicable) •License/Certification Issue Date 9f applicable)
(MM/DD/YYYY) /
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? ❑ YES ❑ NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. is this technician employed by a hospital? ❑ YES ❑ NO
IF YES, furnish the name of the hospital here: _
25 CMS 855B(11/2001)
OMB Approval No. 0938-0685
1 = ,�t�nue ) ,.
D. 4th Non-Physician Personnel Information ❑ Add O Delete O Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? O YES O NO
License/Certification Number(if applicable) License/Certification Issue Date(if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification (if applicable)
3. Is this technician certified by a national credentialling organization? O YES ❑ NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? O YES O NO
IF YES, furnish the name of the hospital here:
AddDelete Change E. 5th Non-Physician Personnel Information O O ❑ g Effective Date:
1. Name First Middle I Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? O YES O NO
License/Certification Number(if applicable) License/Certification Issue Date (if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification (if applicable)
3. Is this technician certified by a national credentialling organization? ❑ YES ❑ NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES O NO
IF YES, furnish the name of the hospital here:
F. 6th Non-Physician Personnel Information ❑ Add ❑ Delete ❑ Change Effective Date:
1. Name First Middle 1 Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY)
/ /
2. Is this technician State licensed or State certified? ❑ YES O NO
License/Certification Number(if applicable) License/Certification Issue Date(if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? O YES O NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES O NO
IF YES, furnish the name of the hospital here:
26 CMS 855B(11/2001)
OMB Approval No. 0938-0685
t W.. ' l L 1, '[{� I�� y j t
This section is to be completed with information about all supervising physicians. If there is more than one supervising
physician, copy and complete this section for each.
A. Supervising Physician Information ❑ Add ❑ Delete O Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
I I (if applicable)
Telephone Number }Ext.) Fax)Number(if applicable) E-Mail address(if applicable)
2. General Supervision
For overall IDTF operation in accordance with 42 CFR 410.33(b),check all that apply for the Supervising Physician reported in
Section 4A1 above:
❑ Assumes responsibility for the overall direction and control of the quality of testing performed.
❑ Assumes responsibility for assuring that the non-physician personnel who actually perform the diagnostic
procedures are properly trained and meet required qualifications.
❑ Assumes responsibility for the proper maintenance and calibration of the equipment and supplies necessary to
perform the diagnostic procedures.
3. Type of Supervision Provided
Check the applicable box below indicating the type of supervising provided by the physician reported in Section 4A1 above
for the tests performed by the IDTF in accordance with 42 CFR 410.32(b)(3)(Definitions).
(Check applicable box) 0 Personal Supervision ❑ Direct Supervision ❑ General Supervision
Note: Personal/ Direct: If this Supervising Physician performs Personal or Direct Supervision, he/she must be currently
enrolled in Medicare with the Medicare carrier to which this application is being submitted.
Note:General: If this Supervising Physician performs General Supervision, he/she must be licensed in all States where he/she
will be performing the General Supervision. If this Supervising Physician is not enrolled with the Medicare carrier to which this
application is being submitted, he/she must submit a copy of his/her current State license for the state in which this application is
being submitted.
B. Attestation Statement for Supervising Physicians
1) I hereby acknowledge that I have agreed to provide(IDTF Name)
with the Supervisory Physician services checked above for all CPT-4 and HCPCS codes reported in Section 1B of
this Attachment(See number 2 below if all reported CPT-4 and HCPCS codes do not apply). I also hereby certify that
I have the required proficiency in the performance and interpretation of each type of diagnostic procedure,as
reported by CPT-4 or HCPCS code in Section 1B of this Attachment(except for those CPT-4 or HCPCS codes
identified in number 2 below). I have read and understand the Penalties for Falsifying Information on this
Enrollment Application, as stated in Section 14 of this application. I am aware that falsifying information may result
in fines and/or imprisonment If I cease providing the stated Supervisory Physician services,I shall immediately
notify the Medicare program.
2) I am not acting as a Supervising Physician for the following CPT-4 and/or HCPCS codes reported in Section 1B of
this Attachment
CPT-4 or HCPCS Code CPT-4 or HCPCS Code CPT-4 or HCPCS Code
3) Signature of Supervising (First, Middle,Last, Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY)
Physician: Signed
27 CMS 855B(11/2001)
MEDICARE
FEDERAL HEALTH CARE
PROVIDER/SUPPLIER ENROLLMENT APPLICATION
RVIC n l fi►
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Application for Health Care
Suppliers that will Bill
Medicare Carriers
CENTERS FOR MEDICARE & MEDICAID SERVICES
CMS 855B(11/2001)
(Formerly HCFA 855)
OMB Approval No. 0938-0685
C ENTERS FOR Medicare
M EDICARE & MEDICAID Provider/Supplier
S ERVICES Enrollment Application
Privacy Act Statemett
he Centers for Medicare and Medicaid Services(CMS) is authorized to collect the information requested on this form by sections
124(a)(1), I124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act[42 U.S.C. §§ 1320a-3(a)(1), 1320a-7, 1395f,
395g, 1395(1)(e), and 1395u(r)] and section 31001O) of the Debt Collection Improvement Act [31 U.S.C. § 7701(c)].
he purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in the Medicare
rogram as providers/suppliers of goods and services to Medicare beneficiaries and to assist in the administration of the Medicare program.
his information will also be used to ensure that no payments will be made to providers or suppliers who are excluded from participation in
he Medicare program. All information on this form is required, with the exception of those sections marked as"optional" on the form.
ithout this information, the ability to make payments will be delayed or denied.
he information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS), and either system number
9-70-0525 titled Unique Physician/Practitioner Identification Number(UPIN) System (published in Vol. 61 of the Federal Register at page
0,528 (May 7, 1996)), or the National Provider Identifier (NPI) System, Office of Management and Budget(OMB) approval 0938-0684(R-
87). The information in this application will be disclosed according to the routine uses described below.
nformation from these systems may be disclosed under specific circumstances to:
) CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
A congressional office from the record of an individual health care provider/supplier in response to an inquiry from the congressional
ffice at the written request of that individual health care practitioner;
The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
Peer Review Organizations in connection with the review of claims, or in connection with studies or other review activities, conducted
ursuant to Part B of Title XVIII of the Social Security Act;
To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States Government is a party
o litigation and the use of the information is compatible with the purpose for which the agency collected the information;
To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which criminal penalties are
ttached;
To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique Physician
dentification Number Registry is unable to establish identity after matching contractor submitted data to the data extract provided by the
MA;
An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or to
he restoration or maintenance of health;
Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers/suppliers of medical services/
upplies or to detect fraud or abuse;
0) State Licensing Boards for review of unethical practices or non-professional conduct;
I) States for the purpose of administration of health care programs; and/or
2) Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care groups providing
ealth care claims processing, when a link to Medicare or Medicaid claims is established, and data are used solely to process provider's/
upplier's health care claims.
he enrolling provider or supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) amended
he Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through computer matching.
Protection of Proprietary Information
rivileged or confidential commercial or financial information collected in this form is protected from public disclosure by Federal law 5
.S.C. § 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal
f any information within this application(or attachments thereto) constitutes a trade secret or privileged or confidential information (as such
erms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal nature such that
isclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then such information will be
rotected from release by CMS under 5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.
2 CMS 855B(11/2001)
OMB Approval No. 0938-0685
INSTRUCTIONS FOR HEALTH CARE SUPPLIERS
THAT WILL BILL MEDICARE CARRIERS
lease PRINT or TYPE all information so it is legible. Do not use pencil. Failure to provide all requested information may
ause the application to be returned and may delay the enrollment process. Certain sections of the application have been
mined because they do not apply to suppliers. See inside front cover for mailing instructions. Electronic copies of all CMS
Medicare enrollment forms can be found at the Medicare web-site at(http://www.hcfa.gov/medicare/enrollment/forms/).
hese electronic forms may be downloaded to your computer, completed on screen, printed, signed, and mailed to the
ppropriate Medicare contractor.
Whenever additional information needs to be reported within a section, copy and complete that section for each additional
ntry. We strongly suggest maintaining a photocopy of this completed application and supporting documents for future
eference.
his application is to be completed by all suppliers that will bill Medicare carriers for medical services provided to Medicare
eneficiaries. Failure to promptly submit a completed CMS 855B to the carrier will result in delays in obtaining enrollment
nd billing privileges.
his form is also used to enroll physician(s), non-physician practitioner(s)and other health care providers/suppliers who form
practice together and bill Medicare as a single supplier. This includes individuals, partnerships, groups, organizations and
orporations, hereafter referred to as "organizations." An individual whose business is incorporated, has received a tax
dentification number for the business, and receives Medicare payment in the name of the business would qualify as an
rganization. Partnership agreements may be requested by the carrier on an "as needed" basis to determine if the partnership
meets State requirements. If a supplier has individual practitioners, each member of the supplier must receive his or her own
nique Physician Identification Number(UPIN) and enroll as an individual (using the Application for Individual Health Care
ractitioners, CMS 855I). Once the individual practitioner is enrolled, he/she can enroll as a member of an organization.
When joining an organization every member of the organization must complete a copy of the CMS 855R(Individual
eassignment of Benefits).
fter completing this enrollment application,the supplier may wish to submit additional forms in the following situations:
To accept assignment of the Medicare Part B payment for all services the supplier renders, the organization should
omplete the form "Medicare Participating Physician or Supplier Agreement" (Form HCFA-460).
To have Medicare payments sent electronically to a supplier's bank account, the supplier should complete the form
Medicare Authorization Agreement for Electronic Funds Transfers" (Form HCFA-588).
To submit claims electronically,the supplier should complete the Electronic Data Interchange (EDI) agreement.
f the supplier plans to do any of the above, submit the appropriate form(s)/agreement(s)with this application. The forms
hould have been received with this initial enrollment package. If not, they can be obtained from the Medicare carrier.
o reduce the burden of furnishing certain types of supporting documentation,we have designated specific types of
ocumentation to be furnished on an "as needed" basis. However, the carrier may request, at any time during the enrollment
rocess, documentation to support or validate information that is reported in this application. Some examples of documents
hat may be requested for validation purposes are billing agreements, IRS W-2s, pay stubs, articles of incorporation, and
artnership agreements.
HOW TO MAKE CHANGES OR UPDATES TO A PREVIOUS APPLICATION
f a supplier changes its tax identification number(TIN), a new enrollment application must be completed, even if most of the
ata on the form remains the same unless the TIN is the only information that is changing(see "Change of Information"
nstructions on page 5). This change will also require that each individual in the newly enrolled supplier submit an updated
MS 855R to reassign his or her benefits to the new supplier. If an existing supplier changes its name/ownership/address,
tc., and there is no change in its tax identification number, the supplier must annotate the change by checking the section
here the change is going to be made, and must sign and date the certification statement. For example, if an existing supplier
s only adding a practice location and has previously completed an application,the supplier completes Sections 1, 4, and 15.
he supplier does not complete a full application. If the supplier is adding or deleting a member who currently is reassigning
is/her benefits to the supplier, it only needs to complete a CMS 855R to make such a change. The member may also delete
is/her reassignment of benefits by completing and submitting the CMS 855R.
3 CMS 855B(11/2001)
OMB Approval No. 0938-0685
DEFINITIONS OF MEDICARE ENROLLMENT TERMINOLOGY
o help you understand certain terms used throughout the application,we have included the following definitions.
Authorized OfficialAn appointed official to whom the supplier has granted the legal authority to enroll it in the Medicare
rogram, to make changes and/or updates to the supplier's status in the Medicare program(e.g., new practice locations,
hange of address,etc.)and to commit the supplier to fully abide by the laws,regulations,and program instructions of
Medicare. The authorized official must be the supplier's general partner, chairman of the board, chief financial officer, chief
xecutive officer,president,direct owner of 5%or more of the supplier(see Section 5 for the definition of a("direct owner"),
r must hold a position of similar status and authority within the supplier organization.
illing Agency-A company that the enrolling supplier contracts with to furnish claims processing functions for the supplier.
Carrier-The Part B Medicare claims processing contractor.
Delegated OfficialAny individual who has been delegated,by the supplier's "Authorized Official,"the authority to report
hanges and updates to the supplier's enrollment record.A delegated official must be a managing employee(W-2)of the
upplier or have a 5%ownership interest,or any partnership interest, in the supplier.
fiscal Intermediary-The Part A Medicare claims processing contractor.
egal Business Name-The name that is reported to the Internal Revenue Service (IRS)for tax reporting purposes.
Medicare Identification Number-This is a generic term for any number that uniquely identifies the enrolling supplier.
xamples of Medicare identification numbers are Unique Physician/Practitioner Identification Number(UPIN), Online
urvey Certification and Reporting number(OSCAR), and National Supplier Clearinghouse(number) (NSC).
Mobile Facility/Portable UnitThese terms apply when a service that requires medical equipment is provided in a vehicle,or
he equipment for the service is transported to multiple locations within a geographic area. The most common types of mobile
acilities/portable units are mobile IDTFs,portable X-ray,portable mammography,and mobile clinics. Physical therapists
nd other medical practitioners(e.g., physicians,nurse practitioners,physician assistants)who perform services at multiple
ocations(i.e., house calls,assisted living facilities)are not considered to be mobile facilities/portable units.
rovider-A provider is a hospital,critical access hospital, skilled nursing facility,nursing facility,comprehensive outpatient
ehabilitation facility, home health agency,or hospice,that has in effect an agreement to participate in Medicare;or a rural
ealth clinic(RHC), Federally qualified health center(FQHC), rehabilitation agency,or public health agency that has in
ffect a similar agreement but only to furnish outpatient physical therapy or speech pathology services;or a community
mental health center that has in effect a similar agreement but only to furnish partial hospitalization services. A provider is not
ynonymous with the corporation or other legal entity that owns or operates the provider. The "provider" is the CMS
ecognized provider type listed above. Therefore, an owning or operating entity may own or operate many providers.
rovider Identification Number(PIN)-This number is assigned to providers, suppliers,groups and organizations in
Medicare Part B. This number will identify who provided the service to the beneficiary on the Medicare claim form.
upplier-A physician or other practitioner,or an organization other than a provider that furnishes health care services under
Medicare Part B. The term supplier also includes independent laboratories,portable x-ray services,physical therapists in
rivate practice,end stage renal disease(ESRD)facilities,and chiropractors. For enrollment purposes, suppliers that submit
laims for durable medical equipment,prosthetics,orthotics,or supplies(DMEPOS)must complete the CMS 855S. This
pplication(CMS 855B) is not for DMEPOS suppliers.
ax Identification Number (TIN)-This is a number issued by the Internal Revenue Service (IRS)that the supplier uses to
eport tax information to the IRS.
Unique Physician/Practitioner Identification Number(UPIN}This number is assigned to physicians,non-physician
ractitioners,and suppliers to identify the referring or ordering physician on Medicare claims.
4 CMS 855B(11/2001)
OMB Approval No. 0938-0685
I7#17151 - 6 6 Ctit' 'MILICATIM1
5 .:A' a Fag IA t ® Y 49 � Z ,
General Instructions
The Medicare Federal Health Care Provider/Supplier Enrollment Application has been designed by the Centers for
Medicare and 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 (x)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.
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 0 Reactivation
❑ Change of Information(Check appropriate Section(s)below and furnish this
supplier's Medicare Identification Number here):
❑ 1 02 ❑ 3 ❑ 4 0 06 08 0 0 1 ❑ 13 ❑ 15 016
Attachment 1- ❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 Attachment 2- ❑ 1 ❑ 2 ❑ 3 ❑ 4
El Voluntary Termination of Billing Number-- Effective Date:
❑ Change of Ownership(Hospitals, Portable X-Ray Facilities,and
Ambulatory Surgical Centers)- Only
2. Tax Identification Number: 6000-813
3. Is this supplier currently enrolled in the Medicare program? ® YES 0 NO
IF YES, furnish the following information about the current carrier:
Current Carrier Name: NORIDIAN 30496
Current Medicare Identification Number.
5 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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)
❑ Ambulance Service Supplier O Multi-Specialty Clinic or Group Practice
❑ Ambulatory Surgical Center O Occupational Therapy Group(complete#2 below)
❑ Diagnostic Radiology Group Practice/Clinic ❑ Other Medical Care Group
❑ Hospital Department(s), Hospital Outpatient Location(s) O Physical Therapy Group(complete#2 below)
and/or Hospital Clinic(s) (complete#4 below) ❑ Physiotherapy Group
❑ Independent Clinical Laboratory(CLIA) 0 Portable X-ray Facility
❑ Independent Diagnostic Testing Facility(IDTF) ® Public Health/Welfare Agency
❑ Mammography Screening Center ❑ Voluntary Health/Charitable Agency
❑ Managed Care Plan (non-Medicare+Choice)
❑ Mass Immunization Roster Biller Only ❑ "Single-Specialty Clinic/Group Practice:
❑ Medicare+Choice Organization *Specify group/clinic specialty below:
❑ 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 0 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? 0 YES 0 NO
e) Does this group furnish PT/OT services outside of its office and/or patients'homes? 0 YES 0 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? 0 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/YYY)
WELD COUNTY GOVERNMENT 07/02/1975
2. "Doing Business As" (DBA)Name(if applicable) County/Parish where DBA Name Registered
WELD COUNTY DEPARTMENT OF PUBLIC HEALTH&ENVIRONMEN (if applicable )
3. Identify the type of organizational structure for this supplier(Check one): COUNTY GOVERNMENT
0 Corporation 0 Partnership ® Other(Specify):
4. Incorporation Date(if applicable)(MM/DD/YYY) State where
/ / Incorporated(if
6 CMS 855B(11/2001)
OMB Approval No. 0938-0685
;
C. Correspondence Address ❑ Change Effective Date:
This must be an address and telephone number where Medicare can contact this supplier directly.
Mailing Address Line 1 1555 N. 17THAVE.
Mailing Address Line 2
City GREELEY State CO 806314117
ZIP Code+4
Telephone Number Ext.) Fax Number(if applicable) E-mail Address (if applicable)
(970)3046410 ( ) (970)3046412
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/YYY):
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.
7 CMS 855B(11/2001)
OMB Approval No. 0938-0685
ants
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
Meommayments? ❑ 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:
8 CMS 855B(11/2001)
OMB Approval No. 0938-0685
4. Cvara4P ldietatinAtlt9y7(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 ❑ Add ❑ Delete ❑ Change Effective Date:
1. Practice Location Name WELD COUNTY DEPT OF PUBLIC HLTH 8 ENVIR Date Started at this Locati n
(MM/DD/YYYY) 85/03/1999
2. Practice Location Address Line 1 1555 N. 17TH AVENUE
Practice Location Address Line 2
City GREELEY County/ WELD State CO ZIP Code+4 80631-9117
Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable)
(97O)304-6410 ( ) (970)304-6412
3. Does this supplier own/lease this practice location? 0 YES ❑ NO
4. Is this practice location a: hospital? 0 YES ❑ NO
retirement/assisted living community? 0 YES 0 NO
group practice office/clinic PUBLIC HEALTH DEPARTMENT ❑ YES 0 NO
other health care facility? (Specify): ® YES ❑ NO
5. CLIA Number for this location (if applicable) FDA/Radiology(Mammography)Certification Number(s)for this
06D0665967 06D0888511 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? 0 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 O 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 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)
/ 1 - ( 1 ( 1 D. Vehicle Information ❑ Add 0 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.
T1. ype of Vehicle (van, mobile home, trailer, etc.) Vehicle Identification Number
NA NA
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.
9 CMS 855B(11/2001)
OMB Approval No. 0938-0685
4. PiattVed•btMkf 4!tnNdUed)
E. Geographic Location where the Base of Operations and/or Vehicle Renders Services
D 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 ❑ Change Effective Date:
Furnish the address where payment should be sent for services rendered at the practice location(s)in Section 4A or 4C.
"Pas To"Address Line 1
"Pigs N 17TH AVENUE
"Pay To"Address Line 2
CitVEELEY State CO
ZI�esr.gn7/ +4
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: 02/01/2002
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 any 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
WELD COUNTYD PARTMEN OF PUBLIC HEALTH AND ENVIRONMENT
Storage Facility Address Line 1
4209 WCR 241/2
Storage Facility Address Line 2
City
LONGMONT State CO 7-yl� X535 +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.
10 CMS 855B(11/2001)
•
OMB Approval No. 0938-0685
Jive J' ' i .S _ .' o SLIP;J •11 eL..f" Ll "_i LE_ ®e'er
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 n. if this section does not apply and skip to Section 6.
B. Organization with Ownership Interest and/or Managing Control-Identification Information
❑ Add 0 Delete 0 Change Effective Date: /
1. Check all that apply: ❑ 5%or more Ownership Interest Effective Date of Ownership
® Managing Control O Partner (MM/DD/YYYY) / /
2. Legal Business Name Effective Date of Control
WELD COUNTY GOVERNMENT (MM/DD/YYYY) — 07/02/1975
3. "Doing D Business PATHE(if appOF PUBLIC HEALTH AND ENVIROMENT T� 6000 ipc� tion Number
WELD COUNTY Name DEPARTMENT OF
4. Bu55 N 17TH AVEN Line 1 Medicare Identification Number(s)
(if applicable)
Business Address Line 2
City GREELEY State CO ZIP Code+4
80631-9117
C. Adverse Legal History O 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? D 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:
11 CMS 855B(11/2001)
OMB Approval No. 0938-0685
( 6. Ons6hipttesleaflndMb rl JingtObad(roination(Inciimituals)
This section is to be completed with information about any individual that has a 5% or greater(direct or indirect)ownership
interest in, or any 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
Z Add ❑ Delete ❑ Change Effective Date: 01/01/2002
1GLWPF First Middle tAD Jr., Sr., etc..
Social Security Number ckt'f-inc) t n b e('n1 F Date of Birth (MM/DD/YYYY) Credentials (M.D., O.D.,
?9-(0000--8)3 of Weld (cavrly / / etc.)
Medicare Identification Number(if Effective Date of Ownership Effective Date of Control
applicable) (MM/DD/YYYY) / / (MM/DD/ 01/01/2002
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.)
O 5%or Greater Owner ❑ Partner ® Managing Employee
O 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: WELD COUNTY DEPT OF PUBLIC HLTH&EN
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 O 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:
12 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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 g if this section does not apply and skip to Section 9.
B. Billing Agency Name and Address 0 Add ❑ Delete ❑ Change Effective Date: 1 1
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.) Fa )
Fax Number(if applicable) E-Mail address(if applicable)
(
C. Billing Agreement/Contract Information 0 Change Effective Date: / /
Answer the following questions about the suppliers agreement/contract with the above billing agency.
1. Does the supplier have unrestricted access to its Medicare remittance notices? 0 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 0 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? 0 YES 0 NO
b) Does the supplier have unrestricted access to the bank account and statements? ❑ YES 0 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? 0 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 suppliers check? 0 YES 0 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
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 suppliers Medicare payment?
13 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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 suppliers 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 El if enrolling in Medicare for the first time and would like to submit claims electronically.
C. 1st 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 Numberi
f
P ( (Ext.) F Number(if applicable) E-mail address (if applicable)
D. 2nd Clearinghouse Name and Address E 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 0 Add ❑ Delete O 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
Telephonee Number (Ext) Fax Number(if applicable) E-mail address (if applicable)
14 CMS 855B(11/2001)
OMB Approval No. 0938-0685
10. Staf ngC+mnt}ta ny
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 X 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 (Ext.) Fax Number
umber(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 (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 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
15 CMS 855B(11/2001)
OMB Approval No. 0938-0685
St�tety c Y f k E TIT S 'OW
",t eithit< lsil kiiiAD s Il
taF l
1 '�:r ratty hteya +t '4� i v t .tZ xs t �jlt jt tt. d d tAt( tx t
a .c r .vw,n,,,v ..dlaidliil I i,....,,. t,.
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 11 if this section does not apply and skip to Section 14.
B. 1st Contact Name and Telephone Number ® Add ❑ Delete ❑ Change Effective Date: / /
Name First Last E-mail Address (if applicable) I Telephone Number (Ext)
WENDY PARIS WPARIS@CO.WELD.CO.US (970)304-6410 (2116)
C. 2nd Contact Name and Telephone Number ❑ Add O Delete ❑ Change Effective Date: / /
Name First Last E-mail Address (if applicable) Telephone Number (Ext.)
JUDY NERO JNERO@CO.WELD.CO.US (970)3046410 (2122)
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,
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
subjectto fines of up to$500,000(18 U.S.C.§3571). Section 3571(d)also authorizes fines of up to twice the gross gaiderived by
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
16 CMS 855B(11/2001)
OMB Approval No. 0938-0685
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
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 O Add O Delete O 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 I authorize 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 agree
to notify the Medicare program contractor of this fact immediately.
Authorized Official Name First Middle Last Jr., Sr., etc.
Print Glenn Vaad
Authorized Officia ft (Firs , Mi le, Last, Jr., Sr., M.D., D.O., etc.) Title/Position Date(MM/DD/YYYY)
Signature p7 Chair, Weld Signed 10/16/02
���111iiY County Board of Commissioners
17 CMS 855B(11/2001)
Xk.2-078/
OMB Approval Na 0938-0685
gatedO#`#ICIa��(Optii��iial} p a
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
A. Check herefl if this supplier will not be assigning any delegated official(s)and skip to Section 17.
B. Delegated Official Signature [] Add O Delete Change❑ 9 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)
I Signed
Title/Position ❑ Check here only if Delegated �r 1 ,z 04 ;, s a
Official is a W-2 employee* ?.?? �� �
,4 t t •
c IT :c Ft 1z ,. <
2. Signature of Authorized Official (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY)
Assigning this Delegation
Signed
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
18 CMS 855B(11/2001)
. OMB Approval No. 0938-0685
ATTACHMENT 1
I! j ::
ued f, r...,.i.a....13.Yh � ,r:e ,.,� .uar...,, ... . i .: 3 a
... : : ....t .... :,. ... ., ` ,I. .,':is M �.....,...m ..
This attachment is to be completed by all ambulance service suppliers enrolling in the Medicare program.
. a %b 6 r I ' �,,, �.:. [ n I :.M I by..r A !°.:
_4�!is_.. ,. • �, i L3 4 : fA-h!! ii}}t.t � ' 3 t{
This section is to be completed with information about the geographic area in which this company furnishes ambulance services.
When applicable, State license information must be provided. In addition, a copy of the current State license must be
submitted with this application.
A. Geographic Service Area ❑ Add ❑ Delete Effective Date: ___ i i
Fumish the county/parish,city, State and ZIP Code for all locations where this ambulance company renders service.
Note: If this ambulance company renders services in more than one State, and those States are serviced 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):
B. State License Information ❑ Add 0 Delete 9 Change Effective Date: /
1. Is this ambulance company licensed in the State where services are rendered and billed for? 0 YES 9 NO
2. IF NO, explain why:
3. IF YES, furnish the license information for the State where this ambulance service supplier will be rendering services
and billing Medicare. Attach a copy of the current State license.
License Number Issuing State(if Issuing County/Parish(if applicable)
applicable)
Date(MM/ -
Effective Date(MM/DD/YYYY) / j Expiration Date(MM/DD/YYYY) / 1
1
19 CMS 855B(11/2001)
OMB Approval No. 0938-0685
12. DeitailititiD9Ziehicle
This section is to be completed with information about the vehicles used by this ambulance company, the equipment they
carry, and the services they provide. If there are more than two vehicles, copy and complete this section as needed. A
copy of each vehicle's registration MUST be submitted. For air ambulance suppliers,attach a copy of FAA 135.
A. 1st Vehicle Information ❑ Add Delete ❑ Change Effective Date:
1. Type (automobile, aircraft, boat, etc.) Vehicle Identification Number
Make Model Year(YYYY)
2. Does this vehicle have the following:
first aid supplies? ❑ YES ❑ NO other safety/life-saving equipment? ❑ YES ❑ NO
oxygen equipment? ❑ YES ❑ NO two-way telecommunications radio? El YES ❑ NO
emergency warning lights? (, .1 YES ❑ NO mobile communication/wireless telephone? ❑ YES ❑ NO
sirens? ❑ YES ❑ NO stretcher? ❑ YES ❑ NO
clean linens? ❑ YES ❑ NO
Report other medical equipment this vehicle carries:
3. Does this vehicle provide:
basic life support(BLS)? ❑ YES ❑ NO land ambulance? E YES H NO
advanced life support(ALS)? ❑ YES ❑ NO air ambulance? ❑ YES h NO
emergency runs? ❑ YES ❑ NO marine ambulance? ❑ YES 77 NO
non-emergency runs? ❑ YES ❑ NO
How many crewmembers accompany this vehicle on runs?
B. 2nd Vehicle Information Add 7 ] Delete -j Change Effective Date:
1. Type (automobile, aircraft, boat, etc.) Vehicle Identification Number
Make Model Year(YYYY)
2. Does this vehicle have the following:
first aid supplies? ❑ YES [] NO other safety/life-saving equipment? 71 YES ❑ NO
oxygen equipment? ❑ YES [ I NO two-way telecommunications radio? r! YES ❑ NO
emergency warning lights? ❑ YES ❑ NO mobile communication/wireless telephone? ❑ YES rl NO
sirens? ❑ YES [] NO stretcher? O YES [j NO
clean linens? ❑ YES ❑ NO
Report other medical equipment this vehicle carries:
3. Does this vehicle provide: �~
basic life support(BLS)? ❑ YES ❑ NO land ambulance? YES ❑ NO
advanced life support(ALS)? ❑ YES ❑ NO air ambulance? L YES ❑ NO
emergency runs? ❑ YES ❑ NO marine ambulance? YES E NO
non-emergency runs? ❑ YES ❑ NO
How many crewmembers accompany this vehicle on runs?
20 CMS 855B(11/2001)
OMB Approval No. 0938-0685
; 4,iai r
This section is to be completed with information about all crewmembers. In addition to the identifying information, all health care
related training courses completed by the crewmember must be reported(see CFR 410.40 and CFR 410.41). If there are more
than five crewmembers, copy and complete this section as needed.
A. 1st Crewmwmember Information 0 Add ❑ Delete ❑ Change Effective Date:
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
B. 2nd Crewmember Information ❑ Add ❑ Delete ❑ Change Effective Date: / /
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
C. 3rd Crewmember Information ❑ Add ❑ Delete 0 Change Effective Date:
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
D. 4th Crewmember Information 0 Add ❑ Delete ❑ Change Effective Date: '
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
E. 5th Crewmember Information ❑ Add ❑ Delete 9 Change Effective Date: /
1. Name First ' Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY)
2. List training completed by this crewmember(i.e., First Aid, CPR, ACLS, etc.)and attach copy(s)of training certificate(s).
21 CMS 855B(11/2001)
OMB Approval No. 0938-0685
This section is to be completed with specific information about the ambulance service supplier if it only furnishes Certified Basic
Life Support(BLS)services.
A. Check here n if this section does not apply and skip to Section 5.
B. Paramedic Intercept Services Information ❑ Change Effective Date:
Does this company have a contract with a paramedic or Emergency Medical Technician(EMT)organization or other Advanced
Life Support(ALS)ambulance supplier whereby the Paramedic/EMT organization or other ALS supplier furnishes Paramedic
Intercept Services? ❑ YES ® NO
IF YES, submit a copy of the signed contractual agreement(s).
%sr c r M ,3'. ... c
This section is to be completed with specific information about the ambulance service supplier if the company furnishes Certified
Advance Life Support(ALS)services.
A. Check here [ f this section does not apply and skip to Section 6.
B. Certified Advanced Life Support Questionnaire ❑ Change Effective Date: / /
1. Is this company certified to perform defibrillation? O YES ❑ NO
IF YES, attach a copy of the certification.
2. Does this company have a contract with a Basic Life Support Service, such as a volunteer ambulance company,
whereby the ALS supplier fumishes Paramedic Intercept Services? ❑ YES O NO
IF YES, submit a copy(s)of the signed contractual agreement(s).
This section is to be completed with information about all Medical Directors associated with this ambulance service supplier.
Some States require ambulance companies to have a Medical Director on staff as a requirement for State licensing. If your
State has such a requirement,this section must be completed. If this ambulance company has more than one Medical
director, copy and complete this section for each.
A. Check here N if a Medical Director is not required by the State where this ambulance company renders
and skip this section.
B. Medical Director Identification ❑ Add ❑ Delete ❑ Change Effective Date: / /
Medical Director First Name Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
22 CMS 855B(11/2001)
OMB Approval No. 0938-0685
ATTACHMENT 2
.f
This attachment is to be completed by all Independent Diagnostic Testing Facilities enrolling in the Medicare program. See
instructions to determine if this supplier needs to complete this Attachment to enroll in Medicare as an IDTF.
:.. i .fynf ..ff:n.f c A�, ; ; j i t P
tP. to t s'!6!ttF f* �!"lielii t i,Y";i i.It3,E?,,
This section is to be completed with information about this IDTF's compliance with current CMS IDTF standards,the types of tests
performed by this IDTF, and the equipment used by this IDTF.
A. Standards Qualifications
Does this Independent Diagnostic Testing Facility meet all current CMS standards for IDTFs? ❑ YES ❑ NO
IF YES, furnish the date that all standards were met:
B. CPT-4 and HCPCS Codes 9 Add ❑ Delete Effective Date: i
Fumish all Current Procedural Terminology,Version 4(CPT-4)codes or HCFA Common Procedure Coding System codes
(HCPCS)for which this IDTF intends to bill Medicare. In addition, report all equipment this IDTF will be using and the model
number of each piece of equipment.
CPT-4 or HCPCS Code Equipment Model Number
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
23 CMS 855B(11/2001)
OMB Approval No. 0938-0685
::up F
� M p W?l j ormatton ion • S .
This section is to be completed with identifying information about all physicians whose interpretations will be billed by this I DTF.
If there are more than eight physicians, copy and complete this section as needed.
A. Check here if this section does not apply and skip to Section 3 of this Attachment
B. 1st Interpreting Physician Information ^, Add i_] Delete ❑ Change Effective Date: '
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
` J
C. 2nd Interpreting Physician Information ❑ Add = Delete ❑ Change Effective Date:
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DDIYYYY) Medicare Identification Number
- . / /
D. 3rd Interpreting Physician Information _; Add ❑ Delete ❑ Change Effective Date:
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
E. 4th Interpreting Physician Information [ Add Delete El Change Effective Date:
Name First Middle Last Jr., Sr., etc.
Social Security Number !Date of Birth (MM/DD/YYYY) Medicare Identification Number
F. 5th Interpreting Physician Information _I Add Delete I 1 Change Effective Date:
Name First Middle ' Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
G. 6th Interpreting Physician Information I I Add ❑ Delete [] Change Effective Date: ' '
Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
. . I 1 J
H. 7th Interpreting Physician Information [_J Add E Delete [I] Change Effective Date: / `
Name First Middle Last Jr, Sr., etc.
Social Security Number (Date of Birth (MM/DD/YYYY) Medicare Identification Number
. . I
I. 8th Interpreting Physician Information [ I Add r-_1 Delete Change,_._ L.� 9 Effective Date:
' Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
Note: All interpeting physicians must be currently enrolled in the Medicare Program.
24 CMS 855B(11/2001)
OMB Approval No. 0938-0685
tpxalicwoewfcnntptifgtanistrottoha:
t-
This section is to be completed with information about all non-physician personnel who perform tests for this IDTF.If there
are more than six technicians, copy and complete this section as needed.
A. 1st Non-Physician Personnel Information n Add ❑ Delete1111 Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? ❑ YES ❑ NO
License/Certification Number(if applicable) License/Certification Issue Date(if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? ❑ YES Li NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES ❑ NO
IF YES, furnish the name of the hospital here:
B. 2nd Non-Physician Personnel Information Li Add I _; Delete I Change Effective Date:
1. Name First Middle 1Last Jr., Sr., etc. .
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? ❑ YES ❑ NO
License/Certification Number(if applicable) License/Certification Issue Date (if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? (_J YES ❑ NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES ❑ NO
IF YES, furnish the name of the hospital here:
C. 3rd Non-Physician Personnel Information ❑ Add Li Delete ❑ Change Effective Date:
1. Name First Middle Last Jr., Sr., etc..
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? ❑ YES ❑ NO
License/Certification Number(if applicable) I License/Certification Issue Date/(;f applicable)
(M M/DD/YYYY)
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? ❑ YES ❑ NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES ❑ NO
IF YES, furnish the name of the hospital here: _
25 CMS 855B (11/2001)
OMB Approval No. 0938-0685
ft *** ., ......_ I .. iRirtalff MSA 1 O 01.:D .:.
D. 4th Non-Physician Personnel Information ❑ Add ❑ Delete ❑ Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? ❑ YES 0 NO
License/Certification Number(if applicable) License/Certification Issue Date(if applicable)
(MM/DD/YYYY) /
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? 0 YES 0 NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? 0 YES 0 NO
IF YES, fumish the name of the hospital here:
E. 5th Non-Physician Personnel Information ❑ Add ❑ Delete ❑ Change Effective Date:
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY) / /
2. Is this technician State licensed or State certified? 0 YES 0 NO
License/Certification Number(if applicable) License/Certification Issue Date(if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification(if applicable)
3. Is this technician certified by a national credentialling organization? ❑ YES 0 NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? ❑ YES 0 NO
IF YES, furnish the name of the hospital here:
F. 6th Non-Physician Personnel Information ❑ Add ❑ Delete ❑ Change Effective Date: /
1. Name First Middle Last Jr., Sr., etc.
Social Security Number Date of Birth (MM/DD/YYYY)
/ /
2. Is this technician State licensed or State certified? 0 YES 0 NO
License/Certification Number(if applicable) License/Certification Issue Date(if applicable)
(MM/DD/YYYY) / /
State of Issuance(if applicable) Type of License/Certification (if applicable)
3. Is this technician certified by a national credentialling organization? 0 YES 0 NO
Name of credentialling organization(if applicable) Type of Credentials (if applicable)
4. Is this technician employed by a hospital? 0 YES 0 NO
IF YES, furnish the name of the hospital here:
26 CMS 855B(11/2001)
• OMB Approval No. 0938-0685
t t ::: :'.'
Im rl ➢1 jT lhkip) .. t
This section is to be completed with information about all supervising physicians. If there is more than one supervising
physician, copy and complete this section for each.
A. Supervising Physician Information O Add ❑ Delete ❑ Change Effective Date: 10/09/2002
1. Name First Middle i Last Jr., Sr., etc. .
Social Security Number Date of Birth (MM/DD/YYYY) Medicare Identification Number
/ / (if applicable)
Telephone Number (Ext) Fax)Number(if applicable) E-Mail address(if applicable)
2. General Supervision (( II
For overall IDTF operation in accordance with 42 CFR 410.33(b),check all that apply for the Supervising Physician reported in
Section 4A1 above:
❑ Assumes responsibility for the overall direction and control of the quality of testing performed.
❑ Assumes responsibility for assuring that the non-physician personnel who actually perform the diagnostic
procedures are property trained and meet required qualifications.
❑ Assumes responsibility for the proper maintenance and calibration of the equipment and supplies necessary to
perform the diagnostic procedures.
3. Type of Supervision Provided
Check the applicable box below indicating the type of supervising provided by the physician reported in Section 4A1 above
for the tests performed by the IDTF in accordance with 42 CFR 410.32(b)(3)(Definitions).
(Check applicable box) ❑ Personal Supervision ❑ Direct Supervision ❑ General Supervision
Note: Personal/ Direct: If this Supervising Physician performs Personal or Direct Supervision, he/she must be currently
enrolled in Medicare with the Medicare carrier to which this application is being submitted.
Note:General: If this Supervising Physician performs General Supervision, he/she must be licensed in all States where he/she
will be performing the General Supervision. If this Supervising Physician is not enrolled with the Medicare carrier to which this
application is being submitted, he/she must submit a copy of his/her current State license for the state in which this application is
being submitted.
B. Attestation Statement for Supervising Physicians
1) /hereby acknowledge that I have agreed to provide(IDTF Name)
with the Supervisory Physician services checked above for all CPT-4 and HCPCS codes reported in Section 1B of
this Attachment(See number 2 below if all reported CPT-4 and HCPCS codes do not apply). I also hereby certify that
I have the required proficiency in the performance and interpretation of each type of diagnostic procedure,as
reported by CPT-4 or HCPCS code in Section 1B of this Attachment(except for those CPT-4 or HCPCS codes
identified in number 2 below). I have read and understand the Penalties for Falsifying Information on this
Enrollment Application, as stated in Section 14 of this application. I am aware that falsifying information may result
in fines and/or imprisonment If I cease providing the stated Supervisory Physician services,I shall immediately
notify the Medicare program.
2) I am not acting as a Supervising Physician for the following CPT-4 and/or HCPCS codes reported in Section 18 of
this Attachment
CPT-4 or HCPCS Code CPT-4 or HCPCS Code CPT-4 or HCPCS Code
3) Signature of Supervising (First, Middle,Last, Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY)
Physician: Signed
27 CMS 855B(11/2001)
. . „„,<.>„,„. . •
ACENTERS FOR MEDICARE&MEDICAID SERVICES
CLINICAL LABORATORY IMPROVEMENT AMENDMENTS
CERTIFICATE OF WAIVER
LABORATORY NAME AND ADDRESS CLIA ID NUMBER
06D0888511
WELD COUNTY HEALTH DEPARTMENT
1555 N 17TH AVE EFFECTIVE DATE
GREELEY, CO 80631 07/08/2002
OLABORATORY DIRECTOR EXPIRATION DATE
MARK WALLACE MD 07/07/2004
V ,
Pursuant to Section 353 of the Public Health Services Act(42 U.S.C.263a)as revised by the Clinical Laboratory Improvement Amendments(CLIA),
the above named laboratory located at the address shown hereon(and other approved locations)may accept human specimens
for the purposes of performing laboratory examinations or procedures.
This certificate shall be valid until the expiration date above,but is subject to revocation,suspension,limitation,or other sanctions
for violation of the Act or the regulations promulgated thereunder. i/-{-
CMS/ Judith A.Yost,Director
Division of Laboratory Services
axrsna.wmivatsaaaurouvmss Survey and Certification Group
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STATE OF COLORADO
DEPARTMENT OF REGULATORY AGENCIES
DIVISION OF REGISTRATIONS >i- ,t
BOARD OF PHA Y � c.
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ACTIVE 4"w , y r.
OTHELIT x
241.0 1 /01/2001 1° 002 ';r, CTO t ce
.�;�'" a¢t (VISION F ISTRATIONS ...x,,„''.4..c--,r
NUMBER ISSUED .IRFS
WELD4EOUNTY DEPT OF PUBLIC HEALTH & ENVIRONMEN if
THOMAS C FLANAGAN
1555 N. 17TH AVE.
GREELEY CO 80631 r
LL ENSTURE � C�^C
SEE REVERSE SIDE FOR OPENING INSTRUCTIONS
STATE O COLORADO \ PRESORTED
DEPARTMENT REGULATORY AGENCIES \\ \ FIRST-CLASS MAIL
DENVER
DIN0531An of Ragisttat On5 U.S.POSTAGE PAID
Suits154 +.'a; wLORADo
Y O t: \ \ / / DPermi No. rado
7M
156pIBrp��N/ay •� A\\\ PermilNo.718
Denver (2p, 202-5140
OFFICIAL DOCUMENT
ENCLOSED WELD COUNTY DEPT OF PUBLIC HEALTH & ENVIRONM
1555 N. 17TH AVE.
GREELEY CO 80631
Ogt&IFIAt_ leatAlaUr ON RE. IN W0•WIEIC15 FejLTW SaftevtoR act ce
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m ,t ST W LD COUNTY f"a < CES
H C FLANAGAN '�-"ter Home An)ress Inch de city,state&Zip Code
42 WELD COUNTY ROPD 24 .5 "' , ,
L( GMONT CO 80504 Eusiness Nate'Ad dress-InalUdeCIw,6tb7e&Zp Co le
ROSEMARY MC COOL Atfse the area above for any ADDRESS or NAME CHANGES
DIRECTORDIVISION OF REGISTRATIONS LICENSEESSIGMATURE 1 THIS is YOUR WALLET CARD EELOWIS YOUR WALL CARD�..
+ To Remove Document Fold and Tear Along This Perforation t
STATE OF COLORADO
DEPARTMENT OF REGULATORY AGENCIES
DIVISION OF REGISTRATIONS .,. • '1 t
BOARD OF PHARMACY
ACTIVE {
-)THER. UT s
25 06/18/2002 1 ,%''2002' , "- of croR z,
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t-7 ISTRATIONS
'�T( NUM6E't� ISSUED EXPA3, '-
SOUT WEST WELD COUNTY. SERVICES BUILDING
THOMAS C FLANAGAN
4209 WELD COUNTY ROAD 24 .5
LONGMONT CO 80504
LICENSEE'S SIGNATURE
s SEE REVERSE SIDE FOR OPENING INSTRUCTIONS
i
.STA,.it 1'�,�, LORADO PRESORTED
DEJARTMENT''REGULATORY AGENCIES FIRST-CLASS MAIL
z Dlvi on Of F2 l5if lIOns EENVE) U.S.POSTAGE PAID
WSuite 1545 > ORA Denveq COIO(adO
I 15608tbaISay A,
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E Denver 0 $0202-5140 Permit No.738
OFFICIAL DOCUMENT
ENCLOSED SOUTHWEST WELD COUNTY SERVICES BUILDING (76
4209 WELD COUNTY ROAD 24.5
LONGMONT CO 80504
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