CMS Pub. 100-08, ch. 10, § 10.3.1.6.1

A. Basic Information (Section 1)

In this section, the supplier indicates the reason for submittal of the application. Unless

otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the

supplier may only check one reason for submittal. Additionally, the supplier will identify its

business and business location in this section.

B. Identifying Information (Section 2)

1. Locations and Addresses - Except for locations used only as warehouse and/or repair facilities,

the supplier must submit a completed Form CMS-855S application for each physical location.

Each address must be a street address as recorded by the USPS, and P.O. boxes will not be

accepted.

2. Hours – The supplier must list their posted hours of operation as displayed at the

aforementioned business location. Unless otherwise stated in this chapter or in another CMS

directive, the supplier shall have a minimum of 30 hours of operation per week.

3. Unavoidable Phone Number or Address Changes – Unless CMS specifies otherwise, any

change in the supplier’s phone number or address that the supplier did not cause (e.g., area code

change, municipality renames the supplier’s street) must still be updated via the Form CMS-

855S.

See section 10.2.5 of this chapter for information on accreditation requirements.

C. Final Adverse Legal Actions (Section 3)

See section 10.6.6 of this chapter for information regarding final adverse actions. Except as

otherwise stated, the PECOS policies in section 10.3 supersede those in section 10.6.6 (e.g.,

communicating with the supplier via the PCV).

D. Important Address Information (Section 4)

See the Important Address Information section of the Form CMS-855S for more background on

this matter.

E. Ownership Interest and/or Managing Control Information (Organizations) (Section 5)

See section 10.6.7 et seq. of this chapter for information concerning owning and managing

organizations.

F. Ownership Interest and/or Managing Control Information (Individuals) (Section 6)

See section 10.6.7 et seq. of this chapter for information concerning owning and managing

individuals.

G. Comprehensive Liability Insurance Information and Surety Bond Information (Section

7)

See section 10.2.5 of this chapter for information regarding comprehensive liability insurance

and surety bond information.

H. Billing Agency Information (Section 8)

(See section 10.6.8 of this chapter for more information on billing agencies. Except as otherwise

stated, the PECOS policies in section 10.3 above supersede those in section 10.6.8.)

If the telephone number in the Billing Agency Information section is blank, the number can be

verified with the supplier by telephone, the PCV, e-mail, or fax. If the entire section is blank

(including the check box), no additional development is necessary.

I. Supporting Documents (Section 12)

See the Supporting Documents section of the Form CMS-855S for information concerning

supporting documents.

J. Contact Person Information (Section 13)

If this section is completely blank, the contractor need not develop for this information and can

simply contact an authorized or delegated official.

If neither box is checked but the contact person information is incomplete (e.g., no telephone

number listed), the contractor can either: (1) develop for this information by telephone, the PCV,

e-mail, or fax; or (2) contact an authorized or delegated official.

There is no existing option on the Form CMS-855S to delete a contact person. The contractor

shall therefore accept end-dates of a contact person via telephone, the PCV, e-mail, fax, or mail

from the individual supplier, the authorized or delegated official, or a current contact person on

file. The contractor shall document in PECOS who requested the termination, how it was

requested (email, phone or fax), and when it was requested. The addition of contact persons

must still be reported via the appropriate Form CMS-855S.

See section 10.6.9 of this chapter for more information on contact persons. Except as otherwise

stated, the PECOS policies in section 10.3 above supersede those in section 10.6.9.

K. Penalties for Falsifying Information (Section 14)

See the Penalties for Falsifying Information section of the Form CMS-855S for an explanation of

penalties that apply to suppliers for deliberately furnishing false information in this application to

gain or maintain enrollment in the Medicare program.