CMS Pub. 100-08, ch. 10, § 10.3.1.3.6

A. Applicability and Format

Unless otherwise specified, the instructions in this section 10.3.1.3.6 apply to (1) signatures on

the paper Form CMS-855I and (2) electronic signatures.

For paper applications, valid signatures include handwritten (wet) signatures in ink and

digital/electronic signatures (digital or electronic signatures such as those created by digital

signature options established via software, such as Adobe). For web applications, electronic

signatures are required; the contractor can contact its PEOG BFL for questions regarding

electronic signatures.

B. Signatories

The enrolling or enrolled physician or non-physician practitioner is the only person who can sign

the Form CMS-855I. (This applies to initial enrollments, changes of information, reactivations,

revalidations, etc.). This includes solely-owned entities listed in the Business Information section

of Section 4 of the Form CMS-855I. A physician or non-physician practitioner may not delegate

the authority to sign the Form CMS-855I on the physician’s/practitioner’s behalf to any other

person. (In the case of death, however, an executor of the estate may sign on behalf of the

deceased supplier, though this only applies to change of information applications.)

C. Paper Submissions

A signed certification statement must accompany the paper Form CMS-855I application. If the

supplier submits an invalid certification statement or fails to submit a certification statement at

all, the contractor shall still proceed with processing the application. An appropriate certification

statement shall be solicited as part of the development process – preferably via the PCV, e-mail,

or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as

reflected by the date of signature) more than 120 days prior to the date on which the contractor

received the application; (d) signed by someone other than the physician or non-physician

practitioner (except as noted in section 10.3.1.3.6(B)); (e) missing; or (f) stamped. The

contractor shall send one development request to include a list of all of the missing required

data/documentation, including the certification statement. The contractor may reject the

supplier’s application if the supplier fails to furnish the missing information on the enrollment

application - including all necessary documentation - within 30 calendar days from the date the

contractor requested it.

Unless stated otherwise in this chapter or in another CMS directive:

(i) The contractor shall begin processing the application upon receipt and shall develop for

missing certification statements and all other missing information.

(ii) The certification statement may be returned via scanned email or fax.

(iii) Signature dates cannot be more than 120 days prior to the receipt date of the application.

(iv) The contractor need not compare the supplier’s signature with one already on file for that

person to ensure it is the same individual.

(v) The contractor shall not request the submission of a driver’s license or passport to verify a

person’s signature or identity.

D. PECOS Submissions

If the supplier submits an invalid certification statement, the contractor shall treat this as missing

information and develop for a correct certification statement – preferably via the PCV, e-mail or

fax. (This includes certification statements that are: signed by someone other than the physician

or non-physician practitioner (except as noted in section 10.3.1.3.6(B)). The contractor shall

send one development request to include a list of all of the data/documentation to be furnished or

clarified, including, as applicable, the certification statement. The contractor may reject the

supplier’s application if the supplier fails to furnish said data/documentation within 30 calendar

days from the date the contractor requested the missing information or documentation.

Unless stated otherwise in this chapter or in another CMS directive:

(i) The contractor shall (a) begin processing the application upon receipt via PECOS, (b) perform

all required manual validations, and (c) develop for any needed clarifying or missing information

or documentation consistent with section 10.3 above and all other applicable instructions in this

chapter.

(ii) The contractor need not compare the supplier’s signature with one already on file for that

person to ensure it is the same individual.

(iii) The contractor shall not request the submission of a driver’s license or passport to verify a

person’s signature or identity.

E. Certification Statement Development

The supplier must submit a newly signed certification statement as part of a development request

as follows:

(i) Paper applications: Via scanned e-mail, fax, or mail. (Only the actual signature page is

required; the additional page containing the certification terms need not be submitted. This also

applies to the supplier’s initial submission of a certification statement; such instances require the

submission of only the signature page and not the certification terms.)

(ii) Web applications – Via electronic signature.

F. Privacy Statement

All information collected on the Form CMS-855I shall be entered into PECOS. The Privacy Act

permits CMS to disclose information without an individual’s consent if the information is to be

used for a purpose that is compatible with the purpose(s) for which the information was

collected. Any such disclosure of data is known as a “routine use.” CMS will only release

PECOS information that can be associated with an individual as provided for under Section III

“Proposed Routine Use Disclosures of Data in the System.” Both identifiable and non-identifiable data may be disclosed under a routine use. CMS will only collect the minimum

personal data necessary to achieve the purpose of PECOS. To view the routine uses in their

entirety, go to: https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Privacy/Downloads/0532-PECOS.pdf.