Who shuould sign Medicare Enrollment form ? Can other than provider sign the form?

Q: Who should sign the certification statement of the CMS-855 provider enrollment application?
A: The following shows the information for the various applications:

CMS-855A and CMS-855B
For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.

The provider can have an unlimited number of authorized officials. However, each authorized official must be listed in section 6 of the CMS-855. Anyone listed as a "Contracted Managing Employee" in section 6 of the CMS-855 cannot be an authorized official.

CMS-855C
For initial enrollment, updating information and voluntarily withdrawing your registration, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

The authorized official signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.

CMS-855I
The only person who may sign the CMS-855I is the individual practitioner, including solely-owned entities listed in section 4A. This applies to initial enrollments, changes of information, reactivations, etc. An individual practitioner may not delegate authority to any other person to sign the CMS-855I on his/her behalf.

CMS-855POH
For physician-owned hospitals complying with the annual reporting requirement, the certification statement must be signed and dated (preferably in blue ink) by an authorized or delegated official. An authorized or delegated official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statutes, regulations, and program instructions of the Medicare program.

The official’s signature must be original. Faxed, stamped, or photocopied signatures cannot be accepted.

The provider can have an unlimited number of authorized or delegated officials. However, each official must be previously reported and approved on the CMS-855A at the time the physician-owned hospital was enrolled or when a CMS-855A was submitted to report a change in the authorized or delegated official.

CMS-855R

For initial reassignment, both the individual and the group's authorized or delegated official must sign section 6. If either signature is missing, First Coast Service Options Inc. (First Coast) will return the application.

If terminating a reassignment, either party may sign section 6; both signatures are not required. If no signatures are present, First Coast will return the application.

The authorized or delegated official who signs section 6 must be currently on file with First Coast.

All CMS-855 applications

If the application is not signed and dated appropriately, the application will be returned. The application will need to be corrected and resubmitted. Any application resubmission must contain a brand new certification statement page containing a signature and date. The provider cannot simply add a signature to the original certification statement submitted.


Q: May an authorized official delegate their authority to sign CMS-855B applications?
A. An authorized official of an organization may delegate authority to make changes to enrollment information and to add physicians/practitioners. The organization must complete the section 16 of the CMS-855B and an authorized official must sign the certification statement. The delegated official must be an individual with an "ownership or control interest" in or be a W-2 managing employee of the supplier. The delegated official must be reported in Section 6.

An individual physician or practitioner cannot delegate authority and must sign the certification statement of the CMS-855I.