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Home My WebLink About20043069 RESOLUTION RE: APPROVE MEDICARE PROVIDER/SUPPLIER ENROLLMENT APPLICATION 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 a Medicare Provider/Supplier Enrollment Application between 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 Colorado Department of Public Health and Environment, with further terms and conditions being as stated in said application, and WHEREAS,after review,the Board deems it advisable to approve said application, a copy of which is attached hereto and incorporated herein by reference. NOW,THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County,Colorado,that the Medicare Provider/Supplier Enrollment Application between 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 Colorado Department of Public Health and Environment be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. The above and foregoing Resolution was,on motion duly made and seconded,adopted by the following vote on the 20th day of October, A.D., 2004. BOARD OF COUNTY COMMISSIONERS WE DCOUNTY^COn E1/4/ LORADO oiginstie� '� J Robert D. Masden, Chair • �,�ty Clerk to the Board 1861 iftsteds e ./ / William H. J e, Pro-Tem /R .1"e ity Clerk to the Board M. ile mos AP V D ORM: Davi E. Long ounty A ney lens a Date of signature: // %/oK I 2004-3069 HL0031 J7G- (it- s) //-G: -(! rie;twas- Memorandum TO: Carol Harding, Office of Clerk to to the Board FROM: Wendy Paris, Dept. of Public Health 0 and Environment COLORADO DATE: October 5, 2004 SUBJECT: Application for an additional Medicare Provider number Enclosed is an application for a Medicare Provider. We are currently a Medicare Provider listed as a Mass Immunization Roster Biller specialty with Medicare. Recently we have been treating tuberculosis clients that are covered by Medicare. According to Medicare, in order to bill for those services we need to apply for an additional Medicare provider number that puts us in a Public Health/Welfare Agency specialty. We need the signature of the Chair of the Board of Commissioners as the authorized official acting in behalf of Weld County, as noted on page 29 of the application. This was also on the application done in October 2002. The signature and date is needed on page 41 of the application. We will then submit the application to Medicare. Please note that the pages that are missing are instructions for filling out the application. Thank you so much for your help in getting this application processed. If you have any questions, please let me know. Enc. 5-1 _a C, vi c) LJ 2004-3069 Memorandum TO: Robert E. Masden, Chair Board of County Commissioners ' C FROM: Mark E. Wallace, MD, MPH Director, Department of Public Health and Environment � w 'wl w r _ CRY DATE: October 14,2004 w i Ito SUBJECT: Application for Additional Medicare Provider Number Enclosed for your approval and signature is an application for an additional Medicare Provider number. The Department of Public Health and Environment (WCDPHE) is currently a Medicare Provider listed with a specialty of Mass Immunizations. Recently, we have been treating tuberculosis clients who are covered by Medicare. In order to bill for these services, WCDPHE must apply for an additional Medicare provider number to identify us as a Public Health/Welfare Agency specialty. As on our previous Medicare application, the Chair of the Board of County Commissioners is the authorized official acting in behalf of Weld County. Thank you for assisting WCDPHE with this application process. Enc. acc1. 's<,�7 MEDICARE FEDERAL HEALTH CARE PROVIDER/SUPPLIER ENROLLMENT APPLICATION 1v~ SERVICES.U �4 `rI t 47 w0 vdaa Application for Health Care Suppliers that will Bill Medicare Carriers CENTERS FOR MEDICARE & MEDICAID SERVICES CMS 855B(11/2001) (Formerly HCFA 855) �c<+/ c `I OMB Approval No.0938-0685 C ENTERS FOR Medicare M EDICARE & MEDICAID Provider/Supplier Enrollment Application S ERVICES Privacy Act Statement The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information requested on this form by sections I 124(a)(1), 1124A(a)(3), 1128, 1814, 1815, I833(e),and 1842(r)of the Social Security Act[42 U.S.C. §§ 1320a-3(a)(1), 1320a-7, 1395f, 1395g, 1395(I)(e),and 1395u(r)] and section 31001(1)of the Debt Collection Improvement Act[31 U.S.C. § 7701(c)). The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in the Medicare program as providers/suppliers of goods and services to Medicare beneficiaries and to assist in the administration of the Medicare program. This information will also be used to ensure that no payments will be made to providers or suppliers who are excluded from participation in the Medicare program. All information on this form is required;with the exception of those sections marked as"optional"on the form. Without this information,the ability to make payments will be delayed or denied. The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS), and either system number 09-70-0525 titled Unique Physician/Practitioner Identification Number (UPIN) System (published in Vol. 61 of the Federal Register at page 20,528 (May 7, 1996)), or the National Provider Identifier (NPI) System, Office of Management and Budget (OMB) approval 0938-0684(R-187). The information in this application will be disclosed according to the routine uses described below. Information from these systems may be disclosed under specific circumstances to: 1) CMS contractors to carry out Medicare functions,collating or analyzing data,or to detect fraud or abuse; 2) A congressional office from the record of an individual health care provider/supplier in response to an inquiry from the congressional office at the written request of that individual health care practitioner; 3) The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts; 4) Peer Review Organizations in connection with the review of claims, or in connection with studies or other review activities, conducted pursuant to Part B of Title XVIII of the Social Security Act; 5) To the Department of Justice or an adjudicative body when the agency,an agency employee,or the United States Government is a party to litigation and the use of the information is compatible with the purpose for which the agency collected the information; 6) To the Department of Justice for investigating and prosecuting violations of the Social Security Act,to which criminal penalties are attached; 7) To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique Physician Identification Number Registry is unable to establish identity after matching contractor submitted data to the data extract provided by the AMA; 8) An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability,or to the restoration or maintenance of health; 9) Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers/suppliers of medical services/supplies or to detect fraud or abuse; 10) State Licensing Boards for review of unethical practices or non-professional conduct; 11) States for the purpose of administration of health care programs;and/or 12) Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care groups providing health care claims processing,when a link to Medicare or Medicaid claims is established, and data are used solely to process provider's/supplier's health care claims. The enrolling provider or supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) amended the Privacy Act,5 U.S.C. § 552a,to permit the government to verify information through computer matching. Protection of Proprietary Information Privileged or confidential commercial or financial information collected in this form is protected from public disclosure by Federal law 5 U.S.C. § 552(b)(4)and Executive Order 12600. Protection of Confidential Commercial and/or Sensitive Personal Information If any information within this application (or attachments thereto) constitutes a trade secret or privileged or confidential information (as such terms are interpreted under the Freedom of Information Act and applicable case law),or is of a highly sensitive personal nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons,then such information will be protected from release by CMS under 5 U.S.C. §§ 552(b)(4)and/or(b)(6),respectively. 1 CMS 855B(11/2001) OMB Approval No.0938-0685 z *t an&9$E iA ,yG sP. *x P" 4Y b+ ( mr h 1111 F3, �FEDERACHEALTH A R DI;WSUPPLIE.A. LLMENT APPLICATION APPlicatid fer g e WA!l 1 Me„dicare.Carriers. General Instructions The Medicare Federal Health Care Provider/Supplier Enrollment Application has been designed by the Centers for Medicare & Medicaid Services (CMS)to assist in the administration of the Medicare program and to ensure that the Medicare program is in compliance with all regulatory requirements. The information collected in this application will be used to ensure that payments made from the Medicare trust fund are only paid to qualified health care suppliers, and that the amounts of the payments are correct. This information will also identify whether the supplier is qualified to render health care services to Medicare beneficiaries. To accomplish this, Medicare must know basic identifying and qualifying information about the supplier that is seeking billing privileges in the Medicare program. If enrolling in the Medicare program as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) do not complete this application. DMEPOS suppliers should contact the National Supplier Clearinghouse (NSC) at 803-754-3951 to obtain a CMS 855S for Medicare enrollment. Medicare needs to know: (1) the type of health care supplier enrolling, (2) what qualifies this supplier to furnish health care related services, (3)where and how this supplier intends to render these services, and (4) those persons or entities with an ownership interest, or managerial control, as defined in this application, over the supplier. This application MUST be completed in its entirety, unless the appropriate box is checked to indicate the section does not apply or when reporting a change to previously submitted information. If a section does not apply to this supplier, check (41) the appropriate box in that section and skip to the next section. Sections 7, 11, and 12 have been deliberately omitted from this application because they are not applicable to the enrollment of suppliers that bill Medicare carriers. 1. General Application Information This section is to be completed with general information as to why this application is being submitted and whether this supplier currently has a business relationship with Medicare or any another Federal health care program. To ensure timely processing of this application, Numbers 1, 2 and 3 below MUST ALWAYS be completed. A. Reason for Submittal of this Application 1. Check one: ®Initial Enrollment ❑ Reactivation ❑Change of Information (Check appropriate Section(s)below and furnish this supplier's Medicare Identification Number here): ❑ 1 02 03 ❑4 ❑ 5 06 08 09 010 013 015 016 Attachment 1 -❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 Attachment 2- ❑ 1 ❑ 2 ❑ 3 ❑4 ❑Voluntary Termination of Billing Number—Effective Date(MM/DD/YYYY): 0 Change of Ownership(Hospitals, Portable X-Ray Facilities, and Ambulatory Surgical Centers)-Only 2. Tax Identification Number: 84-6000-813 3. Is this supplier currently enrolled in the Medicare program? ® YES ❑ NO IF YES,furnish the following information about the current carrier: Current Carrier Name: Noridian Current Medicare Identification Number: 30496 7 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 ❑ Multi-Specialty Clinic or Group Practice ❑Ambulatory Surgical Center ❑ 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 El Mammography Screening Center ❑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 ❑ NO d) Is this private office space used exclusively for the group's private practice? ❑YES ❑ NO e) Does this group furnish PT/OT services outside of its office and/or patients' homes? ❑YES ❑ NO IF YES, provide a copy of the lease agreement which gives the group exclusive use of the facility for PT/OT services. 3. Will this supplier be receiving reassigned benefits from individual practitioners? ❑YES ® NO IF YES, submit a CMS 855R for each individual practitioner who will be reassigning benefits to this supplier. 4. Hospitals Only- If this supplier is a hospital applying for a billing number(s)for Part B practitioner services, check the appropriate box below. See instructions before completing this section. ❑ Single billing number for all departments O Separate billing number for each department listed below B. Supplier Identification Information ❑ Change Effective Date: Furnish the supplier's legal business name (as reported to the IRS), "doing business as" name (name supplier generally known by to the public), and the various operating dates and places of formal business registration and/or incorporation. 1. Legal Business Name as Reported to the IRS Date Business Started (MM/DD/YYYY) 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 & Environer t(if applicable) 3. Identify the type of organizational structure for this supplier(Check one): ❑ Corporation ❑ Partnership ® Other(Specify): County Government 4. Incorporation Date (if applicable) (MM/DD/YYYY) State where Incorporated (if applicable) 9 CMS 855B(11/2001) OMB Approval No.0938-0685 2. ,Supplie, �Jicatlon Qontlnued) ,.. . ,5 C. Correspondence Address O Change Effective Date: This must be an address and telephone number where Medicare can contact this supplier directly. Mailing Address Line 1 1555 N. 17th Avenue Mailing Address Line 2 City State ZIP Code +4 Greeley CO 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) ❑ Change Effective Date: 1. Is this supplier accredited? O YES ❑ NO IF YES, complete the following: O PENDING 2. Date of Accreditation (MM/DD/YYYY): 3. Name of Accrediting Body: E. Comments Explain any unique or unusual circumstances concerning the supplier's practice location(s), the method by which the supplier renders health care services, or any special billing number requirements. 11 CMS 855B(11/2001) OMB Approval No.0938-0685 3. Adverse Legal Actions and Overpayments • This section is to be completed with information concerning any adverse legal actions and/or overpayments that have been 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 E] NO 2. IF YES, report each adverse legal action, when it occurred,the law enforcement authority/court/administrative body that imposed the action, and the resolution. Attach a copy of the adverse legal action documentation(s) and resolution(s). Adverse Legal Action: Date: Law Enforcement Authority: Resolution: Table A 1)Any felony or misdemeanor conviction, under Federal or State law, related to: (a)the delivery of an item or service under Medicare or a State health care program, or(b)the abuse or neglect of a patient in connection with the delivery of a health care item or service. 2) Any felony or misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care item or service. 3)Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section 1001.101 or 1001.201. 4) Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. 5) Any revocation or suspension of a license to provide health care by any State licensing authority. This includes the surrender of such a license while a formal disciplinary proceeding was pending before a State licensing authority. 6)Any revocation or suspension of accreditation. 7) Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or State health care program, or any debarment from participation in any Federal Executive Branch procurement or non-procurement program. 8)Any current Medicare payment suspension under any Medicare billing number. Note: All applicable adverse legal actions must be reported, regardless of whether any records were expunged or any appeals are pending. B. Overpayment Information ❑ Change Effective Date: 1. Does this supplier, under any current or former name or business identity, have any outstanding Medicare overpayments? ❑ YES ® NO 2. IF YES, furnish the name and account number under which the overpayment(s)exists. Name under which the overpayment occurred: Account number under which the overpayment exists: 13 CMS 855B(11/2001) OMB Approval No.0938-0685 THIS PAGE INTENTIONALLY LEFT BLANK 14 CMS 855B(11/2001) • OMB Approval No.0938-0685 4. Current,Practice Locations) 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 E Delete ❑ Change Effective Date:_ 1. Practice Location Name Date Started at this Location Weld County Dept of Public Health & Environment(MM/DD/YYYY) 03/1.0/2.004 2. Practice Location Address Line 1 1555 N. 17th Avenue Practice Location Address Line 2 City County/Parish State ZIP Code +4 Greeley Weld CO 80631-9117 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? Ul YES ❑ NO 4. Is this practice location a: hospital? ❑YES © NO retirement/assisted living community? ❑YES ® NO group practice office/clinic ❑ YES ® NO other health care facility? (Specify): Public Health Department [ 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? ®YES ❑ NO IF YES, use Sections 4C through 4E to furnish information about the mobile/portable services. IF NO, proceed to Section 4F (Medicare Payment"Pay To"Address). C. Base of Operations Address ❑ Add ❑ Delete ❑ Change Effective Date: The base of operations is the location from where personnel are dispatched, where mobile/portable equipment is stored and,when applicable, where vehicles are parked when not in use. See instructions for further examples. Check here X❑ and skip to Section 4D if the "Base of Operations" address is the same as the "Practice Location." 1. Base of Operations Name Date Started at this Location (MM/DD/YYYY) 2. Street Address Line 1 Street Address Line 2 City County/Parish State ZIP Code + 4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( D. Vehicle Information ❑Add ❑ Delete ❑ Change Effective Date: If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish the following vehicle information. See the instructions for a full explanation of the types of vehicles that need to be reported. If more than three vehicles are used, copy and complete this section as needed. 1. Type of Vehicle (van, mobile home, trailer, etc.) Vehicle Identification Number 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. 17 CMS 855B(11/2001) OMB Approval No.0938-0685 r1 ractice Location (COntitiPeck F , „,t fi y E. Geographic Location where the Base of Operations and/or Vehicle Renders Services ❑Add ❑ Delete Effective Date: Furnish the county/parish, city, State and ZIP Code for all locations where mobile and/or portable services are rendered. Note: If this supplier renders mobile health care services in more than one State, and those States are served by different Medicare contractors, a separate CMS 855B enrollment application must be completed for each Medicare contractor jurisdiction. 1. Initial Reporting and/or Additions: County/Parish: City: State: ZIP Code(s): 2. Deletions: County/Parish: City: State: ZIP Code(s): F. Medicare Payment"Pay To" Address ❑ Change Effective Date: 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 1555 N. 17th Avenue "Pay To"Address Line 2 City State ZIP Code+4 Greeley CO 80631-9117 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 O Change Effective Date: 1. Check here ❑ if all patients' medical records are stored at the location shown in Section 4A or 4C, and skip this section. 2. If a�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 County Department of Public Health & Environment Storage Facility Address Line 1 4209 WCR 24 1/2 Storage Facility Address Line 2 City State ZIP Code +4 Longmont CO 80504-9599 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. 19 CMS 855B(11/2001) OMB Approval No.0938-0685 5.' Owners l7 l�;I�' e,;, r IAanaging Control Information (0rgarnaaliitns) This section is to be completed with information about all organizations that have 5% or more (direct or indirect)ownership interest of, any partnership interest in, and/or managing control of, the supplier identified in Section 2B, as well as any information on adverse legal actions that have been imposed against that organization. See instructions for examples of organizations that should be reported here. If there is more than one organization, copy and complete this section for each. A. Check here ❑ if this section does not apply and skip to Section 6. B. Organization with Ownership Interest and/or Managing Control—Identification Information O Add ❑ Delete ❑ 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 Business As" Name (if applicable) Tax Identification Number Weld County Department of Public Health & Environment 84-6000-813 4. Business Address Line 1 Medicare Identification Number(s)(if 1555 N. 17th Avenue applicable) 30496 Business Address Line 2 City State ZIP Code +4 Greeley CO R0691—Q117 C. Adverse Legal History O Change O Effective Date: This section is to be completed only if the organization in Section 5B above is a 5% or greater owner (direct or indirect) of the supplier identified in Section 2B, or has a partnership interest in the supplier identified in Section 2B. 1. Has the organization in Section 5B above, under any current or former name or business identity, ever had any of the adverse legal actions listed in Table A in Section 3A imposed against it? ❑YES O NO 2. IF YES, report each adverse legal action,when it occurred, the law enforcement authority/court/administrative body that imposed the action, and the resolution. Attach a copy of the adverse legal action documentation(s)and resolution(s). Adverse Legal Action: Date: Law Enforcement Authority: Resolution: 25 CMS 855B(11/2001) OMB Approval No.0938-0685 THIS PAGE INTENTIONALLY LEFT BLANK 26 CMS 855B(11/2001) OMB Approval No.0938-0685 6. Ownership Interest and/or Managing Control Information (Individuals) This section is to be completed with information about any individual that has a 5% or greater (direct or indirect) ownership interest in, or any partnership interest in, the supplier identified in Section 28. All officers, directors, and managing employees of the supplier must also be reported in this section. In addition, any information on adverse legal actions that have been imposed against the individuals reported in this section must be furnished. If there is more than one individual, copy and complete this section for each. A. Individual with Ownership Interest and/or Managing Control—Identification Information ❑Add ❑ Delete ❑ Change Effective Date: 1. Name First Middle Last Jr., Sr., etc. Robert Masden Social Security Number*Acting Qn behalf of Date of Birth (MM/DD/YYYY) Credentials (M.D., 84-6000-813 Weld County vita- O.D., etc.) Medicare Identification Number(if Effective Date of Ownship Effective Date of Control applicable) (MM/DD/YYYY) (MM/DD/YYYY) 01/01/2004 2. If the above individual is directly associated with the supplier in Section 28, what is this individual's relationship with the supplier? (Check all that apply.) ❑ 5% or Greater Owner ❑ Partner ] Managing Employee ® Director/Officer ❑ Other(Specify): 3. If the above individual is directly associated with an organization identified in Section 5B, furnish the name of that organization in the space below: Legal Business Name of Organization: rt1 d County Dept of Pohl i r Henl th & Environment 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 ❑ 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 28. 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: • 29 CMS 855B(11/2001) OMB Approval No.0938-0685 7. chaiin ° ' � o'rmatiotr; +'�* T 14-fletion Not Ariplicable r •t4 + ?ffi S. tyt ra IM+x'F15""i Y ' f a N.. 8100*AgencY. This section is to be completed with information about all billing agencies this supplier uses or contracts with that submit claims to Medicare on behalf of the supplier. If more than one billing agency is used, copy and complete this section for each. The supplier may be required to submit a copy of its current signed billing agreement/contract if Medicare cannot verify the information furnished in this section. A. Check here Z] 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.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( C. Billing Agreement/Contract Information ❑ Change Effective Date: Answer the following questions about the supplier's agreement/contract with the above billing agency. 1. Does the supplier have unrestricted access to its Medicare remittance notices? ❑YES ❑ NO 2. Does the supplier's Medicare payment go directly to the supplier? ❑YES ❑ NO IF NO, proceed to Question 3. IF YES, skip Questions 3,4 and 5. 3. Does the supplier's Medicare payment go directly to a bank? ❑YES 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? ❑YES ❑ NO b) Does the supplier have unrestricted access to the bank account and statements? D YES ❑ NO c) Does the bank only answer to the supplier regarding what the supplier wants from the bank(e.g., sweep account instructions, bank statements,closing account, etc.)? ❑ YES ❑ NO 4. Does the supplier's Medicare payment go directly to the billing agent? D YES ❑ NO IF NO, proceed to Question 5. IF YES, answer the following question and skip Question 5. a) Does the billing agent cash the supplier's check? D YES ❑ NO IF NO, proceed to Question b. IF YES, are all of the following conditions included in the billing agreement? 1) The agent receives payment under an agency agreement with the supplier. 2) The agent's compensation is not related in any way to the dollar amounts billed or collected. 3) The agent's compensation is not dependent upon the actual collection of payment. 4) The agent acts under payment disposition instructions that the supplier may modify or revoke at any time. 5) In receiving payment,the agent acts only on behalf of the supplier(except insofar as the agent uses part of that payment as compensation for the agent's billing and collection services). ❑YES ❑ NO b) Does the billing agent either give the Medicare payment directly to this supplier or deposit the payment into this supplier's bank account? ❑YES ❑ NO 5. Who receives the supplier's Medicare payment? 31 CMS 855B(11/2001) OMB Approval No.0938-0685 9; Electronic C a"m nh;rmat on .. 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 98 to start the EDI agreement process. If more than three clearinghouses are used, copy and complete this section as needed. A copy of all currently established EDI agreements for this supplier MUST be submitted with this application. A. Check here® if this section does not apply and skip to Section 10. B. Check here❑ if enrolling in Medicare for the first time and would like to submit claims electronically. C. 1"Clearinghouse Name and Address D 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.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( D. 2n° Clearinghouse Name and Address ❑Add ❑ Delete ❑ Change Effective Date: 1. Legal Business Name as Reported to the IRS Tax Identification Number 2. "Doing Business As" Name (if applicable) 3. Business Street Address Line 1 Business Street Address Line 2 City State ZIP Code +4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( E. 3rd Clearinghouse Name and Address 0 Add 0 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) ( ) ( ) ( 33 CMS 855B(11/2001) OMB Approval No.0938-0685 This section is to be completed with information about all staffing companies that use this supplier, either under written contract or by some other arrangement, to staff any other health care facilities. If this supplier is used by more than two staffing companies, copy and complete this section as needed. The supplier may be required to submit a copy of its current signed staffing company agreement/contract(s). A. Check here ® if this entire section does not apply and skip to Section 13. B. 1"Staffing Company using this Supplier-Name and Address ❑ Add D Delete ❑ Change Effective Date: 1. Legal Business Name as Reported to the IRS Tax Identification Number 2. "Doing Business As" Name (if applicable) 3. Business Street Address Line 1 Business Street Address Line 2 City State ZIP Code +4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( ) C. 1"Staffing Company using this Supplier-Contract/Agreement Information Answer the following questions about the staffing company and the supplier's contract/agreement with them. 1. Does the staffing company shown in Section 106 above and the billing agency identified in Section 86 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? D Not applicable ❑YES D NO D. 2"Staffing Company using this Supplier-Name and Address ❑Add ❑ Delete ❑ Change Effective Date: 1. Legal Business Name as Reported to the IRS Tax Identification Number 2. "Doing Business As" Name(if applicable) 3. Business Street Address Line 1 Business Street Address Line 2 City State ZIP Code+4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( ) E. god Staffing Company using this Supplier-Contract/Agreement Information Answer the following questions about the staffing company's contract/agreement with this supplier. 1. Does the staffing company shown in Section 10D above and the billing agency identified in Section 8B have a common owner(s)? ❑YES D NO 2. If applicable, are there any provisions in the staffing contract/agreement that supersede or contradict the enrolling supplier's billing agreement? ❑ Not applicable ❑YES ❑ NO 35 CMS 855B(11/2001) OMB Approval No.0938-0685 11:Surety Bond Information This Section Not w(lpplicable 12,Capitalization Requirements f r`I,loinef eml`} ;-. e . ,.(this Section Not Applicable 13.Contact Person(s) . .,� �, * � A Furnish the name(s) and telephone number(s) of a person(s)who can answer questions about the information furnished in this application. If a contact person is not furnished in this section, all questions will be directed to the authorized official named in Section 15B. A. Check here❑ if this section does not apply and skip to Section 14. B. 1"Contact Name and Telephone Number❑Add ❑ Delete ❑ Change Effective Date: Name: First Last E-mail Address (if applicable) Telephone Number (Ext.) Wendy Paris paris@co.weld.co.us (970 )304-6410 (2116) C. 2n° Contact Name and Telephone Number❑Add ❑ Delete ❑ Change Effective Date: Name: First Last E-mail Address (if applicable) Telephone Number (Ext.) Judy Nero inero@co.weld.co.us (970 )304-6410 (2122) 14.Peft ifying Information on this Enrollment Applicatipr , „ This section explains the penalties for deliberately furnishing false information to gain enrollment in the Medicare program. 1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false,fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d)also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute. 2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual who, "knowingly and willfully," makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program. The offender is subject to fines of up to$25,000 and/or imprisonment for up to five years. 3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who: a.) knowingly presents, or causes to be presented, to an officer or any employee of the United States Government a false or fraudulent claim for payment or approval; b.) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; or c.) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid. The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of damages sustained by the Government. 4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including an organization, agency or other entity) that knowingly presents or causes to be presented to an officer, employee, or agent of the United States, or of any department or agency thereof, or of any State agency...a claim...that the Secretary determines is for a medical or other item or service that the person knows or should know: a.) was not provided as claimed; and/or b.) the claim is false or fraudulent. This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment of up to three times the amount claimed,and exclusion from participation in the Medicare program and State health care programs. 5. The government may assert common law claims such as "common law fraud," "money paid by mistake," and "unjust enrichment." Remedies include compensatory and punitive damages, restitution,and recovery of the amount of the unjust profit. 37 CMS 855B(11/2001) OMB Approval No.0938-0685 THIS PAGE INTENTIONALLY LEFT BLANK 38 CMS 855B(11/2001) OMB Approval No.0938-0685 15 Certification`s meat eA This section is used to officially notify the supplier of additional requirements that must be met and maintained in order for the supplier to be enrolled in the Medicare program. This section also requires the signature and date thereof of an "Authorized Official" who can legally and financially bind the supplier to the laws, regulations, and program instructions of the Medicare program. Section 16 permits the "Authorized Official" to delegate signature authority to other individual(s) (Delegated Officials) employed by the supplier for the purpose of reporting future changes to the supplier's enrollment record. See instructions to determine who qualifies as an Authorized Official and a Delegated Official for the supplier. A. Additional Requirements for Medicare Enrollment By his/her signature(s), the authorized official named below and the delegated official(s) named in Section 16 agree to adhere to the following requirements stated in this Certification Statement: 1.) I agree to notify the Medicare contractor of any future changes to the information contained in this form within 90 days of the effective date of the change. I understand that any change in the business structure of this supplier may require the submission of a new application. 2.) I have read and understand the Penalties for Falsifying Information, as printed in this application. I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to Medicare, or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the revocation of Medicare billing number(s), and/or the imposition of fines, civil damages, and/or imprisonment. 3.) I agree to abide by the Medicare laws, regulations and program instructions that apply to this supplier. The Medicare laws, regulations, and program instructions are available through the Medicare contractor. I understand that payment of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), and on the supplier's compliance with all applicable conditions of participation in Medicare. 4.) Neither this supplier, nor any 5% or greater owner, partner, officer, director, W-2 managing employee, authorized official, or delegated official thereof is currently sanctioned, suspended, debarred, or excluded by the Medicare or Medicaid program, or any other Federal program, or is otherwise prohibited from supplying services to Medicare or other Federal program beneficiaries. 5.) I agree that any existing or future overpayment made to the supplier by the Medicare program may be recouped by Medicare through the withholding of future payments. 6.) I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare, and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity. B. Authorized Official Signature ❑Add ❑ Delete ❑ Change Effective Date: I have read the contents of this application. My signature legally and financially binds this supplier to the laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the information contained herein is true, correct, and complete, to the best of my knowledge, and 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 oroaram contractor of this fact immediately. Authorized Official Name First Middle Last Jr., Sr., etc. Print Robert Masden Authorized Official ^((Frs Middle, Last,)r.,, Sr., M.D., D.O., etc.) Title/Position Date(MM/ D/YYYX Signature \\�� LA�1C 1Vrw, chair, Weld CountySignedQC 2 0 L0(4 oard of Commissioners 41 CMS 855B(11/2001) y 2G6 `i OMB Approval No.0938-0685 THIS PAGE INTENTIONALLY LEFT BLANK 42 CMS 855B(11/2001) OMB Approval No.0938-0685 16 DM at °fflca (Optio `al)`,; tr The signature of the authorized official below constitutes a legal delegation of authority to the official(s) named in this section to make changes and/or updates to this supplier's enrollment information. The signature(s) of the delegated official(s) shall have the same force and effect as that of the authorized official, and shall legally and financially bind the supplier to the laws, regulations, and program instructions of the Medicare program. By his or her signature, the delegated official certifies that he or she has read the Certification Statement in Section 15 and agrees to adhere to all of the stated requirements. The delegated official also certifies that he/she meets the definition of a delegated official. When making changes and/or updates to the supplier's enrollment information maintained by the Medicare program, the delegated official certifies that the information provided is true, correct, and complete. If assigning more than one delegated official (maximum of three), copy and complete this section as needed. A. Check here® if this supplier will not be assigning any delegated official(s) and skip to Section 17. B. Delegated Official Signature 0 Add ❑ Delete ❑ Change Effective Date: 1. Delegated Official Name First Middle Last Jr., Sr., etc. Print Delegated Official (First, Middle, Last,Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY) Signature Signed Title/Position OCheck here only if Delegated Official pis F f is a W-2 employee* • ,, *4 2. Signature of Authorized Official (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Date(MM/DD/YYYY) Assigning this Delegation Signed 17iAttacl fit$ 4 .r„ ). � • 1s is 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. DCopy(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 DCopy(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 DCopy(s)of all professional school degrees or certificates, or evidence of qualifying course work DCopy(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 DCopy(s)of all adverse legal action documentation (e.g., notifications, resolutions,and reinstatement letters) DCopy(s)of all current signed electronic data interchange (EDI)agreements DCopy(s)of all partnership agreements DCopy(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) DAny additional documentation or letters of explanation as needed 45 CMS 855B(11/2001) . „„,,,..,„„ . „,,,, . ................ moromammemonessoarmomerommommar t % CENTERS FOR MEDICARE &MEDICAID SERVICES CLINICAL LABORATORY IMPROVEMENT AMENDMENTS CERTIFICATE OF COMPLIANCE . i s LABORATORY NAME AND ADDRESS CLIA ID NUMBER 9 WELD CNTY DEPT OF PUBLIC HLTH & ENVIR 0600665967 1555 NORTH 17TH AVENUE EFFECTIVE DATE r GREELEY, CO 80631 06/13/2004 LABORATORY DIRECTOR EXPIRATION DATE JERRY WEIL MD 06/12/2006 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 0 for the purposes of performing laboratory araminations or procedures. I , 5 This certificate shall be valid until the expiration date above,but is subject to revocation.suspension,limitation,or other sanctions ! h for violation of the Act or the regulations promulgated thereunder. $ . CA1SJudith A.Yost,Director Division of Laboratory Services ' .) , ornsQaweKaetismrrosnrars Survey and Certification Group Center for Medicaid and State Operations F, ' 94)1' • ks ... <1.. ' . - 7 A '411 4.14444: 0:::: ...... 1.>: ::Mtlik..•1• Pr• ao:60 ot. 0)0,.. :::. 44.. > le, :::>•"."4411 4% If you currently hold a Certificate of Compliance or Certificate of Accreditation,below is a list of the laboratory specialties/subspecialties you are certified to perform and their effective date: LAB CERTIFICATION (CODE) EFFECTIVE DALE LAB CERTIFICATION(CODE) EFFECTIVE DATE BACTERIOLOGY(110) 03/11/2004 MYCOLOGY(120) 03/07/2002 PARASITOLOGY(130) 06/13/1994 SYPHILIS SEROLOGY(210) 06/13/1994 GENERAL IMMUNOLOGY(220) 03/11/2004 FOR MORE INFORMATION ABOUT CLIA,VISIT OUR WEBSITE AT WWW.CMS.HHS.GOV/CLIA OR CONTACT YOUR LOCAL STATE AGENCY.PLEASE SEE THE REVERSE FOR YOUR STATE AGENCY'S ADDRESS AND PHONE NUMBER. PLEASE CONTACT YOUR STATE AGENCY FOR ANY CHANGES TO YOUR CURRENT CERTIFICATE. ..4. -44 .: ,..4401C4C.Op.> .. , - T. : CENTERS FOR MEDICARE&MEDICAID SERVICES CLINICAL LABORATORY IMPR OVEMENT ROVEMENT AMENDMENTS CERTIFICATE OF WAIVER LABORATORY NAME AND ADDRESS CLIA ID NUMBER WELD COUNTY HEALTH DEPARTMENT 06O0888511 1555 N 17TH AVE EFFECTIVE DATE • GREELEY, CO 80631 e • 07/08/2004 ?) LABORATORY DIRECTOR EXPIRATION DATE • MARK WALLACE MD 07/07/2006 4 4 t • Pursuant to Section 353 of the Public Health Services Act(42 U.S.C.263a)as revised by the Clinical Laboratory Improvement Amendments(WA), r' the above named laboratory-located at the address shown hereon(and other approved locations)may accept human specimens a for the purposes of performing laboratory examinations or procedures. p p This certificate shall be valid until theexpiration date + above,but is subject to revocation,suspension,limitation.or other sanctions for violation of the Act or the regulations promulgated thereunder. . ‘.. t _ o ,e C �3 Judith A.Yost,Director w Division of Laboratory Services • r ; MIASv.s�roeirsaraosrrt>xr Survey and Certification Group Center for Medicaid and State Operations •.A } r � I yi�v+ 681 c040609 � • If this is a Certificate of Registration,it represents only the enrollment of the laboratory in the CLIA program and does not indicate a Federal certification of compliance with other CLIA requirements.The laboratory is permitted to begin testing upon receipt of this certificate,but is not determined to be in compliance until a survey is successfully completed. • If this is a Certificate for Provider-Performed Microscopy Procedures,it certifies the laboratory to perform only those laboratory procedures that have been specified as provider-performed microscopy procedures and,if applicable, examinations or procedures that have been approved as waived tests by the Department of Health and Human Services. • If this is a Certificate of Waiver, it certifies the laboratory to perform only examinations or procedures that have been approved as waived tests by the Department of Health and Human Services. • FOR MORE INFORMATION ABOUT CLIA,VISIT OUR WEBSITE AT WWW.CMS.HHS.GOV/CLIA OR CONTACT YOUR LOCAL STATE AGENCY. PLEASE SEE THE REVERSE FOR YOUR STATE AGENCY'S ADDRESS AND PHONE NUMBER. PLEASE CONTACT YOUR STATE AGENCY FOR ANY CHANGES TO YOUR CURRENT CERTIFICATE. FTD ADDRESS CHANGE employer Identification Number(EIN) °Me No.1545-0257 An address change here changes your 8 4'f b 0 0 0 8 13 , 141712 4 3 address on the El)coupons only. iirliaiion% ei i,�si�iiiis+iseeiti,iaisaitlisishili�titi 29 g COUNTY 'OF WELD s ' OFFICE O.F TI4E COMPTROLLER 1s Ad t PO BOX 758 Address GREELEY CO 80632-0758 City State --- --- o INTERNAL REVENUE SERVICE CENTER X OGDEN, UT 8420} •1 Telephone Number.. f Send FTD Address Change and correspondence to the IRS address above. Memorandum ' TO: Carol Harding, Office of Clerk to the Board C FROM: Wendy Paris Department of Public Health & Environment COLORADO DATE: February 7, 2005 SUBJECT: Signature on Reassignment of Benefits for Medicare Application for one of our nurses. We have one of our Nurse Practioners, Cynthia Horn, enrolling as a Medicare Provider. Medicare requires a Reassignment of Benefits application completed so that any payment on claims will come to Weld County and not to Cynthia. Commissioner Masden is our authorized delegate on the original Medicare application for Weld County, so we need his signature on the Reassignment of Benefits application. The application basically states that Cynthia wants to reassign any Medicare reimbursements for services she renders to Medicare clients to go to Weld County. Commissioner Masden's signature is needed on page 7 of the attached Reassignment of Benefits application. Thank you for your time and help in this matter. If there are any questions, please let me know. Att. MEDICARE FEDERAL HEALTH CARE REASSIGNMENT OF BENEFITS APPLICATION dtptI SERVICES 461 Est w0 wvelara Application for Individual Health Care Practitioners to Reassign Medicare Benefits CENTERS FOR MEDICARE & MEDICAID SERVICES CMS 855R(11/2001) (Formerly HCFA 855R) OMB Approval No.0938-0685 MEDICARE FEDERAL HEALTH CARE BENEFIT REASSIGNMENT APPLICATION Application for the Reassignment of Medicare Benefits General Instructions The Medicare Federal Health Care Benefit Reassignment Application has been designed by the Centers for Medicare & Medicaid Services (CMS)to assist in the administration of the Medicare program and to ensure that the Medicare program is in compliance with all regulatory requirements. The information collected in this application will be used to ensure that payments made from the Medicare trust fund are only paid to qualified health care providers or suppliers with whom an individual practitioner has a valid reassignment of benefits on file with Medicare, and that the amount of the payments are correct. To accomplish this, Medicare must know basic identifying information about the individual practitioner and the provider/supplier who the individual practitioner is authorizing to receive payment on his or her behalf for services rendered to Medicare beneficiaries. When completing this application, Medicare must know the name, social security number, and Medicare identification number of the individual practitioner reassigning his or her benefits and the name, tax identification number, Medicare identification number, and practice locations of the supplier receiving the individual practitioner's reassigned benefits. This application must be completed any time an individual practitioner reassigns his or her benefits to an eligible provider/supplier. Both the individual practitioner and the eligible provider/supplier must be currently enrolled (or concurrently enrolling) in the Medicare program. Generally, this application will be completed by the provider/supplier, signed by the individual practitioner, and submitted by the provider/supplier. When deleting a current reassignment, it is the individual practitioner's responsibility to submit this application with the appropriate sections completed. 1. General Application Information This section is to be completed with information as to why this reassignment of benefits application is being submitted. Reason for Submittal of this Application Check one: ®Add a New Reassignment ❑Terminate a Current Reassignment—Effective Date: ❑Add a New Practice Location(s)for a Current Reassignment ❑ Delete a Practice Location(s)from a Current Reassignment ❑ Change Income Reporting Status- Effective Date (MM/DD/YYYY): 2. Provider/Supplier Identification This section is to be completed with identifying information about the provider/supplier to which the individual practitioner is reassigning his or her benefits. Legal Business Name of Provider/Supplier as Reported to IRS County of Weld (Public Health Dept) Tax Identification Number Medicare Identification Number 84 6000 813 800648 3. Individual Practitioner Identification This section is to be completed with identifying information about the individual practitioner who will be reassigning (or terminating the reassignment of) his or her benefits to the provider/supplier shown in Section 2 above. Name First Middle Last Jr., Sr., etc. Cynthia Kay Horn Social Security Number Medicare Identification Number pending applic'tion What income reporting form does the individual practitioner receive from the supplier at the end of the calendar year based on his or her relationship with the provider/supplier shown in Section 2? Check all that apply: ®W-2 ❑ 1099 O 1065-K1 Other: 3 CMS 855R(11/2001) OMB Approval No.0938-0685 4. Practice Location This section is to be completed with all practice locations of the provider/supplier identified in Section 2 indicating where the individual practitioner identified in Section 3 will be rendering services on a regular basis. If more than four locations need 1.. hn n......A...l .......,..n,� .........L.M Il.in nnn.. ..e .......1...! A. 1st Practice Location Information ❑Add ❑ Delete Effective Date: 1. Practice Location Name Date practitioner began/will start renderinc services Weld County Dept of Public Health at this location (MM/DD/YYYY) 01./01 /20.0.5 2. Practice Location Street Address Line 1 1555 N. 17th Avenue Practice Location Street Address Line 2 City County/Parish State ZIP Code +4 Greeley Weld Colorado 80631-9117 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address(if applicable) (370 )304-6410 ( ) ( 970) 304-6412 B. 2nd Practice Location Information 0 Add ❑ Delete Effective Date: 1. Practice Location Name Date practitioner began/will start rendering services at this location (MM/DD/YYYY) 2. Practice Location Street Address Line 1 Practice Location Street Address Line 2 City County/Parish State ZIP Code +4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address(if applicable) ( ) ( ) ( ) C. 3r° Practice Location Information ❑Add ❑ Delete Effective Date: 1. Practice Location Name Date practitioner began/will start rendering services at this location (MM/DD/YYYY) 2. Practice Location Street Address Line 1 Practice Location Street Address Line 2 City County/Parish State ZIP Code+4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( ) D. 4`" Practice Location Information ❑Add 0 Delete Effective Date: 1. Practice Location Name Date practitioner began/will start rendering services at this location (MM/DD/YYYY) 2. Practice Location Street Address Line 1 Practice Location Street Address Line 2 City County/Parish State ZIP Code+4 Telephone Number (Ext.) Fax Number(if applicable) E-mail Address (if applicable) ( ) ( ) ( ) 5 CMS 855R(11/2001) OMB Approval No.0938-0685 5. Statement of Termination This section is to be completed by the individual practitioner when terminating a previously authorized reassignment of benefits. By my signature, I hereby terminate the authority of to claim or receive any fees or charges for my services. (Name of Individual or Provider/Supplier as Reported to the IRS) I certify that I have examined the above information and that it is true, accurate and complete to the best of my knowledge. I understand that any deliberate misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws. Individual Practitioner Name First Middle Last Jr., Sr., etc. Print Individual Practitioner Signature (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY) Signed 6. Reassignment of Benefits Statement This section MUST be signed and dated by the individual practitioner shown in Section 3 to authorize the reassignment of his or her benefits to the provider/supplier shown in Section 2. Medicare law prohibits payment for services provided by an individual practitioner to be paid to another individual or provider/supplier unless the individual practitioner who provided the services specifically authorizes another individual or provider/supplier (employer, facility, or health care delivery system) to receive said payments in accordance with 42 CFR 424.73 and 42 CFR 424.80. By signing this Reassignment of Benefits Statement, you are authorizing the individual or provider/supplier identified in Section 2 to receive Medicare payments on your behalf. Your employment or contract with this individual or provider/supplier must be in compliance with CMS regulations. All individual practitioners who allow another individual or provider/supplier (employer, facility, or health care delivery system) to receive payment for their services must sign the Reassignment of Benefits Statement. I acknowledge that, under the terms of my employment or contract, County of Wel d is entitled to claim or receive any fees or charges for my services. (Name of Individual or Provider/Supplier as Reported to the IRS) Individual Practitioner Name First Middle Last Jr., Sr., etc. Print Cynthia Kay Horn Individual Practitioner (Firs/t, Mid 4l , Last, Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY) Signature �t y �t.y. V c Pc Signed - z/ 5 7. Attestation Statement This section requires the signature of an authorized or delegated official of the provider/supplier shown in Section 2. The authorized or delegated official must currently be on file with Medicare for this application to be processed. I certify that I have examined the above information and that it is true, accurate and complete to the best of my knowledge. I understand that any deliberate misrepresentation or concealment of any information requested in this application may subject me to liability under civil and criminal laws. I certify that the provider/supplier requesting to receive payments is legally eligible to receive reassigned benefits per CMS regulations. Authorized/Delegated Official Name First Middle Last Jr., Sr., etc. Print Robert D. Masden Authorized/ g Q{f cia , (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Date (MM/DD/YYYY) Signature D� Ar _ Signed n^H/y-as-- 7 CMS 855R(11/2001) Hello