Supporting Documents

Attach required supporting documentation for individuals or organizations.

Submit applicable documents.

CMS-588 EFT Authorization Agreement and voided check or bank confirmation letter
IRS document confirming your legal business name and EIN (e.g., IRS, CP-575 or CP-147C)
Medical license/certification
National Certification and diploma for nonphysician practitioners
Drug Enforcement Administration (DEA) certification
Business license
Organizational Structure Diagram/Flowchart
Final adverse legal action documentation
Accreditation
CMS-460 Medicare Participating Physician or Supplier Agreement
Application fee receipt or hardship exception request
Documentation verifying IDTF supervisory physician(s) proficiency and/or state licenses or certifications for IDTF nonphysician personnel
Comprehensive liability insurance policy (IDTFs only)
Documentation verifying state licenses or certifications of the laboratory director or nonphysician practitioner personnel of an independent clinical laboratory
FAA 135 certification (air ambulance suppliers)
Ambulance vehicle registration
Mobile/Portable vehicle registration
Attestation for government entities and tribal organizations
IRS Form 8832 confirmation of disregarded entity
Lending relationship ‒ Statement in writing from the bank detailing agreement to waive its rights of offset for Medicare receivables

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