CMS Pub. 100-08, ch. 10, § 10.3.2.11

Authorized Officials)

(Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25)

(Unless indicated otherwise below or in another CMS directive, the instructions in this section

apply to (1) signatures on the paper Form CMS-20134, and (2) signatures for PECOS

applications.)

For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures

(digital or electronic signatures such as those created by digital signature options in

software, such as Adobe) are acceptable. For web applications, the supplier can sign it

electronically or upload the signature and then submit the application. The contractor shall

contact its PEOG BFL for questions regarding electronic signatures.

A. Paper Submissions

A signed certification statement shall accompany the paper Form CMS-20134. If the

supplier submits an invalid certification statement or no certification statement at all, the

contractor shall still continue processing the application. An appropriate certification

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

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

was signed (as reflected by the date of signature) more than 120 days prior to the date on

which the contractor received the application; (d) missing altogether; or (e) stamped. The

contractor shall send one development request that lists all of the missing/deficient required

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

supplier’s application if the supplier fails to furnish the missing information and/or correct

the deficient data on the enrollment application - including all necessary documentation -

within 30 calendar days from the date the contractor requested the information or

documentation.

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

• The contractor shall begin processing the application upon receipt and shall develop

for missing/deficient certification statements and all other missing/deficient

information, including the application fee, upon review.

• As applicable, the certification statement may be returned via scanned email or fax.

• As mentioned previously, signature dates cannot be prior to 120 days of the receipt

date of the application.

• For paper applications that require development, it is only necessary that the dated

signature of at least one of the supplier’s authorized or delegated officials be on the

certification statement that must be sent in within 30 days; the signatures of the

other authorized and delegated officials need not be obtained.

• For paper change of information applications (as the term “changes of information”

is defined in section 10.4 et al. of this chapter), if the certification statement is

signed by an individual who is not on file with the contractor as being an authorized

or delegated official of the supplier, the contractor may accept the certification

statement but shall develop for information on this person.

• The contractor need not compare the signature on the Form CMS-20134 with the

same authorized or delegated official’s signature on file to ensure that it is the same

person.

• The contractor shall not request the submission of a driver’s license or passport to

verify a person’s signature or identity.

B. PECOS Submissions

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 and all other applicable instructions in

this chapter.

(ii) 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,

email, or fax. (This includes certification statements that are signed by a person unauthorized to

do so under 42 CFR Part 424, subpart P.) The contractor shall send one development request

that includes a list of all of the data/documentation to be furnished or clarified, including, as

applicable, a correct 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 of

the contractor’s request.

(iii) For PECOS applications that require development, at least one of the supplier’s authorized

or delegated officials has to sign any certification statement that must accompany the supplier’s

response. Obtaining the signatures of the other authorized and delegated officials is not required.

(iv) For PECOS changes of information (as the term “changes of information” is defined in

section 10.4.4 of this chapter), if the certification statement is signed by an individual who is not

on file with the contractor as an authorized or delegated official of the supplier, the contractor

may accept the certification statement. However, it shall develop for information on the person

in question consistent with the procedures in this chapter.

(v) The contractor is not required to compare the signature thereon with the same supplier’s,

authorized official’s, or delegated official’s signature on file to ensure that it is the same person.

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

person’s signature or identity.

C. Certification Statement Development

If, as already mentioned, the supplier submits an invalid certification statement (as described in

subsections (A) and (B)), the contractor shall develop for a correct certification statement and

send a development letter to the supplier. The provider must submit the requested certification

statement as follows:

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

required; the provider need not submit the additional page containing the certification terms.

(This also applies to the provider’s initial submission of a certification statement. Such instances

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

(ii) PECOS applications – Via electronic or uploaded signature.

D. Authorized Officials

Except as stated otherwise, the instructions in this section 10.3.2.11(D) apply to: (1)

signatures on the paper Form CMS-20134; and (2) electronic or uploaded signatures for

PECOS applications.)

1. Requirements

As defined in 42 CFR § 424.502, an authorized official is an appointed official (for example,

chief executive officer, chief financial officer, general partner, chairman of the board, or direct

owner) to whom the organization has granted the legal authority to enroll it in the Medicare

program, to make changes or updates to the organization’s status in the Medicare program, and

to commit the organization to fully abide by the statutes, regulations, and program instructions of

the Medicare program. The person must have the authority to legally and financially bind the

supplier to) the requirements set forth in 42 CFR § 424.510 (and other applicable Medicare

regulations) and to act on behalf of the organization.

An authorized official is not restricted to the examples of the titles outlined above;

however, the person must hold a position of similar status and authority within the provider

or supplier organization. Additional titles could include, but are not limited to, executive

director, administrator, president, and vice-president. The contractor shall consider the

individual’s title and the authority granted by the organization when determining whether

an individual qualifies as an authorized organization. If the contractor is unsure of the

person’s qualifications or authority, it shall contact its PEOG BFL for further clarification.

The contractor shall obtain PEOG BFL approval if the only role of the listed authorized

official is “Contracted Managing Employee.”

If an authorized official is listed as a “Contracted Managing Employee” in the Individual

Ownership and/or Managing Control section of the Form CMS-20134 and does not qualify

as an authorized official under some other category in this section, the individual cannot be

an authorized official. The contractor shall notify the supplier accordingly. If the person is

not listed as a “Contracted Managing Employee” in the Individual Ownership and/or

Managing Control section and the contractor has no reason to suspect that the person does

not qualify as an authorized official, no further investigation is required. Should the

contractor have doubts that the individual qualifies as an authorized official, it shall contact

the official or the applicant's contact person to obtain more information about the official's

job title and/or authority to bind. If the contractor remains unconvinced that the individual

qualifies as an authorized official, it shall notify the supplier that the person cannot be an

authorized official. If that person is the only authorized official listed and the supplier

refuses to use a different authorized official, the contractor shall deny the application.

For purposes of determining an authorized official’s qualifications, identifying the supplier

is not determined solely by the supplier’s TIN. Rather, the organizational structure is the

central factor. For instance, suppose a chain drug store, Company X, wants to enroll 100 of

its pharmacies with the contractor. Each pharmacy has a separate TIN and must therefore

enroll separately. Yet all of the pharmacies are part of a single corporate entity – Company

X. In other words, there are not 100 separate corporations in our scenario but merely one

corporation whose individual locations have different TINs. Here, an authorized official

for Pharmacy #76 can be someone at X’s headquarters (assuming the definition of

authorized official is otherwise met), even though this main office might be operating

under a TIN that is different from that of #76. This is because headquarters and Pharmacy

#76 are part of the same organization/corporation.

2. Required Signature

For Form CMS-20134 initial applications, the certification statement must be signed and

dated by an authorized official of the supplier. (See sections 10.1.1 and 10.3.2.11(D) of this

chapter for a definition of “authorized official.”) The supplier can have an unlimited

number of authorized officials so long as each meets the definition of an authorized

official. The Individual Ownership and/or Managing Control section of the Form CMS-

20134 must be completed for each authorized official.

(For revalidation and changes of information, either the authorized or delegated official

must sign the application. (See sections 10.1.1 and 10.3.2.12 of this chapter for a definition

of “delegated official.”).

3. Changes and Deletions in Authorized Officials

A change in authorized officials does not impact the authority of existing delegated

officials to report changes and/or updates to the supplier's enrollment data or to sign

revalidation applications.

If an authorized official is being deleted, the contractor need not obtain (1) that official’s

signature or (2) documentation verifying that the person is no longer an authorized official.

4. Authorized Official Not on File

If the supplier submits a change of information (e.g., change of address) and the authorized

official signing the form is not on file, the contractor shall ensure that: (1) the person meets

the definition of an authorized official; and (2) the Individual Ownership and/or Managing

Control section of the Form CMS-20134 is completed for that person. The signature of an

existing authorized official is not needed to add a new authorized official. Note that the

original change request and the addition of the new official shall be treated as a single

change request (i.e., one change request encompassing two different actions) for purpose of

enrollment processing and reporting.

5. Effective Date

The effective date in PECOS for the Certification Statement section of the Form CMS-

20134 should be the date of signature.

6. Social Security Number

To be an authorized official, the person must have and must submit a social security

number (SSN). An Individual Taxpayer Identification Number (ITIN) cannot be used in

lieu of an SSN in this regard.

7. Telephone Number

The authorized official’s telephone number can be left blank. No further development is

needed.