Supporting Documentation Information

Supporting documentation with the submission of an application is very important. The paper CMS-855A identifies applicable information under section 17.

Here’s a list when applicable for initial enrollment, change of information or revalidation.

• Application fee (initial enrollment, revalidation and adding a practice location)
• License/ Certifications/ Registrations by Medicare or State law
• License/ Certifications/ Registrations to operate a health care facility
• IRS confirming Tax Identification Number and/or determination of nonprofit
• IRS form 8832 confirming LLC as a disregarded entity
• CMS-588 for initial, CHOW or to update banking including a voided check or bank confirmation letter
• Any change of ownership application will need copies of the bill of sale/stock transfer with both the seller and buyer signature with effective date identified
• Statement from lending bank to waiver the right of offset for Medicare receivables
• Final adverse action documentation for enrollee, any organization or individual identified in enrollment with ownership or managing control
• Attestation for government or tribal organization and CMHC enrollment specialty
• Organizational structure diagram/flowchart of all owners/managing control is needed if section 5 is completed, include relationships identified under section 6
• SNF need to complete an organizational structure diagram/flowchart of all owners/managing control for the organizations and individuals identified in Attachment 1, including disclosable parties
• Vehicle registration/ license
• CLIA
• FDA
• ADA
• CMS-1561 for Initial enrollment, change of ownership is needed by all specialties excluding FQHC, REH, CAH, ESRD and RHC
• CMS-1561A for Initial enrollment, change of ownership is needed for RHC 
• HHS 690 for initial enrollment and change of ownership is needed by all specialties excluding FQHC and RHC
• Documents that demonstrate meeting capitalization requirements for a Home Health Agency
• Action Plan for a Rural Emergency Hospital
• CMS-3427A for an End-Stage Renal Disease Facility
• Exhibit 177 for a Federally Qualified Health Center
• HRSA Notice of Award approving practice location for a Federally Qualified Health Center

Revised 10/31/2024