DME Enrollment Issues &How to Avoid Disenrollment

Moderated by Paul Kesselman DPM

Participants Karen Hurley, CMM, CPC, President of HPMSI

Katherine Sharp, BA, President of Keystone Professional Solutions

Sponsored by PICA

June 25, 2014

Disclaimer The contents of this lecture and handouts are to serve as a reference point for the provision of DME and its reimbursement and are solely the opinion of Dr. Kesselman, Karen Hurley and Katherine Sharp. These opinions are not necessarily endorsed or shared by PICA or APMA. One should check with your health care attorney and liability carrier for further advice and with your patient’s insurance carrier for coverage information. Products discussed and/or illustrated are provided as examples and not necessarily an endorsement of their use. Dr. Kesselman is a board member of Visual Foot Care Technology and consultant to EHR and DME Manufacturers. Karen Hurley is President of HPMSI and Katherine Sharp is owner of Keystone Professional Solutions. Both have extensive experience with administrative issues concerning medical billing for podiatrists. Any reproduction of this presentation in any format without their express written permission is prohibited.

DME For Dummies •  ALJ Administrative Law Judge •  COI Certificate of Insurance •  DME MAC’s Durable Medicare Equipment Administrative Contractor •  DOS Date of Service •  DWO Detailed Written Order (Similar to Prescription) •  LCDs Local Carrier Decision •  NPI National Provider Identifier •  NSC National Supplier Clearinghouse •  OIG Office of Inspector General •  O&P Orthotics and Prosthetics •  OTS Off the Shelf •  PDAC Price Data Analysis Contractor •  POD Proof of Delivery •  POE Provider Outreach and Education •  PSC Program Safeguard Contractor •  PTAN Provider Transaction Number •  RAC Recovery Audit Contractor •  SACU Supplier Auditing Contractor Unit •  TPA Third Party Administrator

Enrollment in Medicare DMEPOS

National Supplier Clearinghouse

Palmetto GBA, AG-495P.O. Box 100142

Columbia, SC 29202-3142 IVR: (866) 238-9652

*Also in Region C: Puerto Rico & The U.S. Virgin Islands

Claims paid by Jurisdiction of Patient’s Home Address

 

JURISDICTION INCLUDED STATES DME MAC

A Connecticut, Delaware, District of Columbia, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont

National Heritage Insurance Company

B Illinois, Indiana , Kentucky , Michigan, Minnesota , Ohio , and Wisconsin

National Govt Services (NGS)

C Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia, and West Virginia

Cigna Gov’t Svcs

D Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, Missouri, Montana, Nebraska, Nevada, North Dakota, Northern Mariana Islands, Oregon, South Dakota, Utah, Washington, and Wyoming

Noridian Administrative Services

DME MAC’s •  DME MAC A: 866-419-9458 www.nhic.com/dmerc.html

•  DME MAC B: 877-299-7900  www.ngsmedicare.com •  DME MAC C: 866-238-9650

www.cignagovernmentservices.com •  DME MAC D: 877-320-0390 www.noridianmedicare.com/

dme •  PDAC: 877-735-1326 Help Desk www.dmepdac.com •  NSC: 803-754-3951 www.palmettogba.com/nsc

Don’t forget Your Non MCR Third Party Payers (TPP)!!

Requirements for DPMs to Enroll in DMEPOS

•  NPI Type I As Prescribing/Ordering/Referring DPM

•  NPI Type II as the Billing Entity •  Tax ID Number with IRS Documentation •  $300K Liability Insurance (Not Your Malpractice) •  Insurance Policy Must List NSC as Certificate

Holder •  $542 Application and Processing Fee Per

Location •  Copy of Your State License •  Application May be Paper or Electronic •  Completed Application •  EFT Application, CEDI Application (If Electronic

Billing), Site Inspection

Application ProcessIs it That Complicated?

•  Solo vs Group Practice •  Single Location vs. Multiple Office

Location •  Corporation vs Solo Practioner •  Par vs. Non Par

What is Required to Become DMEPOS?

•  Enrollment Fee Is Mandatory for DMEPOS •  CMS 855S “The Application” •  CMS 588 (“EFT”) •  CMS-460 (“Participation Agreement”)

DME Application Fee For 2014 – the fee is $542.00 You must pay online The automated receipt copy must go with your

application

Where Do I pay the Application Fee?

•  www.palmettogba/medicare •  Click on NATIONAL SUPPLIER CLEARINGHOUSE

(on the left side menu) •  Under SELF SERVICE TOOLS, click on “Medicare

Enrollment Fees” •  You will be taken to the web page that appears

on the next slide

Medicare Payment Web PageBe certain to have your practice information handy – then click on ‘CONTINUE’

Complete this section, then click on ‘PAY NOW’ at the bottom of the screen

What happens next……

•  You will receive an email that shows the fee has been paid (you may also be able to print an instant receipt.)

•  A copy of this email must sent with the

application, along with the email(s) you received enrolling for your Organization NPI.

The Dreaded Application

Paper or Electronic?

http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855s.pdf

IXW1WNT Of M.(ALfH AHO J.«JMAH SERVK£S QNll ltS JOit MU)l(M( a MrotCAID SER\llGS

DMEPOS SUPPLIER STANDARDS FOR MEDICARE ENROLLMENT

llolow ts an •-•r.d swnm.lfY of the standards evefY Medlatt1 DMEPOS suppt1or mun meet In ordor to obtain and ,._ lhelr bdffng p!!,,.__ These stondords. Jn ther enUrety. lnwdlng the >urtty bond pro"111on>. ""'llsttd In •2 CFR i 414.$7(0 and (d} and gn be found .at bnp•Uwww cms.goytMectt(arepnw!1uQfnmll!Q DMEJtoSSuppll«Sunctp amftopOtPm

A >UPl>lier mU51 be In compll;ince "'1th all appllcable "-al and Stai. llol>nswe and reQIJatory requiremems.

2. A SUPPiier mU51 provide complete ond am.nte

1n1omiauon on the OMEl'OS SUIJllller appkmon. An1 ct..._ to INs lnfonnJUon IDU5t be reponro to the ,.._,..Suppler~- 30doys..

3 AA.il>l*er .....,,..... an...cl>orllro-...i wflose

1'gnal\ft IS~ llgrl the - appllc;>tlon for l>ftnO """--

• A supplw - Ill onion from ltS own """"1oiy or conlrall """ - - tor the purthase ot 1tm1< ........, to Ill ordon.. A allJlll« GmOt c:onuoa wnh atry tntlty lllot 11 NT<!llllJ U<Uled from the Medicare _ ..... ..., sui. he.Jltll c;are programs. or mt -"-al procurom..nt or noo-proaJrement prognms.

5 A supplier mU51- benelklart<!S lhot they may""" or purcNM lnQl!IOflSlve or rouunely purchased durable rntdlCal equipment, and of the JUc11ase opdOn for capped rtnul oquJpment.

6 A suppl1« mun notify benefl<W1es of w.irr.mty covtt .ago ~ honor ~11 wa~nties under app11able Sut1 •~. and rtp.Jlr or replace free of charge Medkare COVQf'td rttnu that are u:ndGr warranty.

7. A syppl1tr must malnbln a physKaJ fadltty on an ;ppropnato Sitt and must maintain a v1s1ble S!gn with POrtod hours of operation. The locatlon must be accos11blo to tho publl< and staffed during posted hours of bUSJnoss. ThQ l0<at1on must~ at least 200 square fott ;nd cont111n spa<q for storing records.

8. A supplior must pormn CMS or Its agents to conduct

15. A suppller must acct11t rwturm of subsl.and¥d Oeu INn fUI quallty for the p.wucuor n-i or unsurt.ablt lt«n> o_ .. lorthe-flCl>ry at thet111141 ft -flmd and,_ ortold)IT°"'-

16. A~ mU51 dlldoM U-SUncbnll to Nell

bontf10M)' n IUPl*4S • - n... 17 A~ - dlllcloM M'f- ""'ng _...,,,,.,.

flnanaal or corct011n- on the IUPPllor 18. ,. _must not conwy or N"'9' • IUPl>lier

no-. u . the~ moy _,..,or - anothor entity to use IU' ~·Dang,_

19. """"""'must,.....• comp1o1ra moluaon prococol --IO--llCl.vyc--Wt­to mos. sundaRls. A reccnl of 1MM cornplotnts mU51 b4 mairutr-.d •t the pllyllc.al faClllty

20. Complaint records mull lnduclt tho na1114. adclr• ut.phone number and htollll l111Ur .,,.t claim numbtr of the llenthciaty. a summaiy or the comploint. and at'! acoons won to ,.,.,,._ n

21 A •uppli.r must agrM to furn11h CMS any lnformauon required by thO Mtd1<ar• natut• and rtQul•tlOns.

22. A supplier must b4 accrodlttd by • CMS·•PProved .a<<redruuon organ11at1c>n 1n ordor to r1et1vo and retain a suppl1or b1ll1no numbor Tho Kcrodtiauon must lnd1me tho Sl)OClflC prod ucu and sorv1co1 for wh~h tho supphor K ac.crodltod In ordor for tho 1upphor to rocoivo payment fO< thoso sptclflC products ond sorv1<os (Ol<COPt for <~rta 1n txompt phorm1,out1uts),

on.Sitt 1nspoct1ons t o ascertain the su,pplle(s compllance 24. with 1119so stand•rds.

23. A supplier must nouty th·Olr 1ccrod1t; t1on org11n1iauon when a now OMEPOS locauon IS o~nod.

All supplier locouons, whothor ownod or sutxontractod. must meot tht OMEl'OS qu•l~y standards and b4

9. A $UPP11tr must maintain a pr1mary business telephone llntd un<SQf' the name of the business In a local directory or a toll troe number av.ilable through directory iHISUnct. Tht t•dwtve use of a beeper. answenng machl..._ a_,ng ""111oe or ceU phone dunng posted buslntU "°"""prohibited.

10 A suppllO< mU51 haw comprMen!M! hablllty lns.Gnce In the amount of at least SJoo.000 tlldt C<M'IS both 1119 IUIJl>ltr'S pla(e of bu!llll!SS and all customen ond ...,._of the suppilef. 11 the supplier maootacnns llS _, lt«n> thll lr1Annte must also cowr proclJct llOOllll)' and complettd -.-...

11 A suppllet 11 prohl>lted ITOm <lrect 50ll<1tolloo m - btnt-._ Fu complete _on this ~ * 42 cm§ 424.57(<)(1 l).

12. A SllPIJllW 11 ,__for -...Y of and ""'5l ln5Uua

- on the use of Medlo>re COfm!d "- and ....,...n proof or dolM<J and beneftOarJ ln5UUCtlOn.

11 """""*"""'--and <--1 to ~of---..-~ of lUCll CC<UCt>.

I• A supplier mlSl mainbln and ropbce at no chorge or r-COil - clrectly or through • seNICe controa "'111 another company. ¥'f M-..re-covered ttems n has rO<lltd IO btnoll<lar11!5.

,.P•rately accrod1tod 1n ordor to blll Mtd!Qro 25. A supplier must dKdoso upon onrollmont all products

•nd Stl'VICOS. Including tho llddlUon of now Product llnes for whlCh they aro soollll'lg acatdlUUon

26. A supplier mU51 """'t tho suroty bond roquiremonu Sfl«lfltd In 42 CFR § •2H7(d)

27. A suppllO< mU51 obuin oiwon ftom •stat..._ -~ 28. A supplier mU11 maintain onllr1ng and rtl«nng doaJmtntauon .-tnt "'111 P<0"1SIOnl - In U CFR § U• 516(1)

29. A $U11C11W 11 proNbrttd fr°"' lllMlng • pracuc. IOCallon ---...pr--~

30. A~---tOthe~fora

- of )I) ho<n per - IJICOlll ~las - 1n - 1141Q> 01 01 the AcO. p11y11ea1 anc1 ~""'-or OM£P05 .....,.wor\Jng wnll CllSlOm made or111oOO and prOSllWUcl

What Are Supplier Standards?

§  Standards of Business Conduct §  30 Supplier Standards §  Not All Apply to DPMs

1. A supplier must be in compliance with all applicable Federal and State licensure and regulatory requirements and cannot contract with an individual or entity to provide licensed services. 2. A supplier must provide complete and accurate information on the DMEPOS supplier application. Any changes to this information must be reported to the National Supplier Clearinghouse within 30 days. 3. An authorized individual (one whose signature is binding) must sign the application for billing privileges. 4. A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs. 5. A supplier must advise beneficiaries that they may rent or purchase inexpensive or routinely purchased durable medical equipment, and of the purchase option for capped rental equipment.

Supplier Standards 1-5

6. A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty. 7. A supplier must maintain a physical facility on an appropriate site. This standard requires that the location is accessible to the public and staffed during posted hours of business. The location must be at least 200 square feet and contain space for storing records. 8. A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation. 9. A supplier must maintain a primary business telephone listed under the name of the business in a local directory or a toll free number available through directory assistance. The exclusive use of a beeper, answering machine, answering service or cell phone during posted business hours is prohibited. 10. A supplier must have comprehensive liability insurance in the amount of at least $300,000 that covers both the supplier’s place of business and all customers and employees of the supplier. If the supplier manufactures its own items, this insurance must also cover product liability and completed operations.

Supplier Standards 6-10

11. A supplier must agree not to initiate telephone contact with beneficiaries, with a few exceptions allowed. This standard prohibits suppliers from contacting a Medicare beneficiary based on a physician’s oral order unless an exception applies. 12. A supplier is responsible for delivery and must instruct beneficiaries on use of Medicare covered items, and maintain proof of delivery. 13. A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of such contacts. 14. A supplier must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. 15. A supplier must accept returns of substandard (less than full quality for the particular item) or unsuitable items (inappropriate for the beneficiary at the time it was fitted and rented or sold) from beneficiaries.

Supplier Standards 11-15

16. A supplier must disclose these supplier standards to each beneficiary to whom it supplies a Medicare-covered item. 17. A supplier must disclose to the government any person having ownership, financial, or control interest in the supplier. 18. A supplier must not convey or reassign a supplier number; i.e., the supplier may not sell or allow another entity to use its Medicare billing number. 19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility. 20. Complaint records must include: the name, address, telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

Supplier Standards 16-20

21.A supplier must agree to furnish CMS any information required by the Medicare statute and implementing regulations. 22.All suppliers must be accredited by a CMS-approved accreditation organization in order to receive and retain a supplier billing number. The accreditation must indicate the specific products and services, for which the supplier is accredited in order for the supplier to receive payment of those specific products and services (except for certain exempt pharmaceuticals). Implementation Date - October 1, 2009 23. All suppliers must notify their accreditation organization when a new DMEPOS location is opened. 24. All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare. 25. All suppliers must disclose upon enrollment all products and services, including the addition of new product lines for which they are seeking accreditation.

Supplier Standards 21-25

Supplier Standards 26-30

26. Must meet the surety bond requirements specified in 42 C.F.R. 424.57(c). Implementation date- May 4, 2009 27. A supplier must obtain oxygen from a state- licensed oxygen supplier. 28. A supplier must maintain ordering and referring documentation consistent with provisions found in 42 C.F.R. 424.516(f). 29. DMEPOS suppliers are prohibited from sharing a practice location with certain other Medicare providers and suppliers. 30. DMEPOS suppliers must remain open to the public for a minimum of 30 hours per week with certain exceptions.

WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION

Th• following types of Durable Me<fica l Equipment, Prosth•tics, Orthotlcs and SuppllM (DMEPOS) suppll•11 must complete this application to enroll in the Medicare program and receive a Medicare Billing number:

Ambulatory Surgical Center ~partment Store Grocery Store Home Health Agency Hosp.ta I Indian Health Semce or Tnt..I F.alrty Intermediate Care Nurs1n9 Faohty Medial 5...,py Company

Nursing Facility (other) Ocularist Occupational Therapist Optician Orthotics Pe..o~I Oxygen and/or Oxygen Relate<! EquipMnt Supplier Pedorthic Penonnel Pharmacy

Ph)llkal Therapist Phl!lic4 1, 111dud1110 ~ntlst and Optometrist Pronhotla Personnel ProsthetJc/Orthotlc Personn•I Rehab<htatlon Agency Slulled Nuning f..:ll1ty s~ t..borator)iModiono Sports Medione

If Y'O'Jr DMEPOS supplier type is not listed. contact the Nauonal Supploor 0.AnnQhouso MedocMe AdmlflHtratl\le Controctor (NS( MAO before you submit this application.

Complete thos -location if you plan to bill or al<eady btll MedJG1re for DMEPOS and you «• • Enrolino ., Medicar• for the first time as a DMEPOS suppl.or

Currontly enrolled 1n Medicare as a DMEPOS ~and need to report d>angoo to your rurrent bus.nos!, (• o, you are adding, remoWlg, or <hanging existing Wlfu<matl«I under the ModUr• R1P1>ltor btllong number). Changes must be reporte<f within 30 days of the change

Currontly •nroUed in Medicare as a DMEPOS suppt,.r and need to enroll a new builness lo<.uon """II th• wmo t .. identification number already enrolled wrth th• NSC MAC.

• Currently •nrolled in Medicare as a DMEPOS supplier and need to enroll a now business loutlon using a t .. ldont1fication numbe< not currently enrolle<f wrth the NSC MAC.

• Curre-ntly enrolJt'd in Medicare as a DMEPOS supplier and received notKe to re-validate your enrollment. • React1vat1no your Medicare DMEPOS supplier billing number. • Voluntarily t•rminating your Medicare DMEPOS supplier billing number

DMEPOS suppli•rs can apply for enro llment in the Medicare program or make a change In their •nrollmont information using either: • The Internet-based Provider Enrollment, Chain and Owne11h lp S)/ltem (PECOS), or

• The paper CM S-8555 enrollment application. Be sure you are using the n'ost current version. For oddltlonal In formation rega rding the Med icare enrollment process, Including Internet-based PECOS and lo get the current version of the CM S-SSSS, go to htto:l/www.cms.goy/Med!c1reProyiderSupEnroll.

BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATION

The Medicare Identification Number, often referred to as a Medkare supplier number Of' Medicare billing number is a generk term for any number other than th• National Provider ld•ntlfl•r (NPI) that Is used by a DMEPOS suppll•r to bill the Medicare program.

The National Providor Identifier (NP!) is the standard unique hoalth ld•ntJfl•r for h•alth car• pr0Yide11 and suppli•n and is assigned by the National Plan and Pro111der Enumeration Syst•m (NPPES). To become• Medure DMEPOS supplier, you must obtain an NPI and f.....W. it on this •ppll<.otlon prior to •nrolling in Medl<.ore or when submitting a change to your existing Mediaro 01'rollment information. Applying for th• NPI b a process .._ate from Me<ficare enrollment. To obtain an NP!, you may apply onhn• at httm:/lnDOH, ems. hhs goy For more information about HPI enurneranon. vtSJt www mn oovlN••Joo•IPmytdrntStand NOTE: Tho l.ogal BJJIUl6S Name (lBN) and Tax Identification Number ffiNl that you fum!Sh In SoctJon 18 of thts apploc.uon must be the same LBN and TIN you used to obtam Y<KK NPI. One• the intonn.uon 11 ontered Into PE COS from thos application, Y'O"' LBN, TIN and NPI must match euctly on both the Medcar• PrCMdor Enrollment Cha., and Ownership System and the Nanonal Plan and PrOYlder Enumor auon S)/ltom

INSTRUCTIONS FOR COMPUTING THIS APl'UCATION

Al W>formatl«I on thJS form is required with the excoptlon of those fields ,_ifk.ally marled• "opb«\al • Any f~ marted as optional is not required to be completed n« doe 1t need to bo upd1ted or roported as a "change of mforrnatl«I" as required in 42 CFR § 424516. Howewr, 1t 11 hiohly recommondod that If reported, those fields be kepi up-to-date.

INSTRUCTIONS FOR COMPLETING THIS APPLICATION (Conrinued)

• Type or print all information so that it is legible . Do not use pendl. Blue Ink k prof erred. • When ~sary to report additional information, copy and compl•t• the apphuble section as nttded. At~ all supportmg documentation. Kttµ. \.UV)' ur JVUI \.Uffl..,lt"lt:t.I Mc-ilit.ott" t"l'Wul11ncul f>cK.k~ rui )'Vt.II VW11 ·~ .• uuh.

TIPS TO AVOID DELAYS IN YOUR fNROll.MENT

Complete all required sections as shown in Section l ; Complete Section 9 for all delegated and authorized offidak ,._.ed on Sections 14 •nd 15; ~at lust one ownet' and one managing employff for •ad> loabO<\

• Enter your NPI on the applicable sections; • lndude the El«tronoc FWlds Transf..- (EFT) Agr-eemern (CMS-588), who<\ -lic;oble, wnh yout enrollment ~bOI\ ~ tJmoly to deftlopment/infonnation requem; and Be ..,, the legal Busmess Name shown in Section 1 B matche< the name on your wo clotuments

Addouonal tnfom..tJOn and reasons for processing delays can t... found at www Dt!mtnoqbt mrn(ng.

PROCESS FOR OBTAINING MEDICARE APPROVAL

The standard proass for beconung a Medicare DMEPOS wpplier k as follows; I The supplier obtains the required National PrOOiider Identification Number (NPI), wrety bond and/or

.caedrt.ation PIUOR to completing and submitting this application to the NSC MAC. 2 The supplier completes and submits this enrollment application (CMS-8555) and •II supporting

documentatJon to the NSC MAC 3 The NSC MAC r..,,ews the application and conducts a site 11isit to verify compliance with the wpplier

standards found at 42 CFR § 424.57, 424.58, and 42 CFR § 424.S00-565. 4, After completing its review, the NSC MAC notifies the supplier in writing about Its enrollment dedJlon.

ADDITIONAL INFORMATION

The NSC MAC may r.,quest additional documentation to support or validate Information reported on this application. You are responsible for providing this documentation within 30 days of the r.,quest.

The lnform•tlon you provide on this form is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(G), respe<tlve ly. For more information, see the last page of this application to read the Prlvocy Act Statem•nt.

ACRONYMS COMMONLY USED IN THIS APPLICATION

CFR: Code of Federal Regulations DME MAC: Durable Medical Equipment Medicare Administrative Contractor DMEPOS: Our•ble Medical Equipment, Prosthetics, Orthotia and Supplies EfT: Electronic Funds Transfer IRS: Internal R...enue Sonnee Liit ~gal Business Nome U.C: limited l'6bollly (orporatton

NPI: National Provider ld•ntlfler NPPES: National Plan and Provld<!r Enumeration System NSC MAC: National Suppher Oearinghouse Medicare Admlnistrauve Contr.ctor PECOS: PrOY1der Enrollment Chain and Ownenhop System

SSN: Sodal Se<urity Number TW: Tu ldentJfication Number

WHERE TO MAil YOUR APPLICATION

NotOONI Supplier a.,annghouse Post OffQ Bo. 100142 Columbia. SC 29202-3142 Cuuomer Sonnee. I "66-233-9652 Wt'b bnp=l/www polmcttggba com/me

Overnight Mal&ng Addr<:H: National Supplier Clearonghouw Palmetto GBA • AG-495 BOO Spnngdale Dr1Ye. Bldg Camden, SC 29020

Org. Type II NPI Each Location Must Have Separate NPI

Multiple NPI’s May Be Linked to Same Tax ID #

SECTIO N 1: BAS IC IN FORMATIO N (Continued)

C. REASON FOR SUBMlnlNG THIS APPLICATION Check on<! box and complete the Sections as indicated.

location with " t4K MAC.

lion number

0 You are a M W enrollee in Medk.are or are enrolling a new klentiflc.otJon number not previously enrolled with the NSC

0 You are adding a new business location using a tax identifica

Complete all R<tlon1

Complete R<tlons 1- 7. 9 currently enrolled with the NSC MAC.

D You are ..tdong • new buJiness location using a tax identification NOT currently enrollt!d with the NSC MAC.

0 You 11tt rucdvwng your ~Supplier 8iling lbnber

D You 11tt mralodallnil your Mt!dKare enrolment.

0 You are YO!unr.ily tenniMtirlg your M edO... ""'°"'1>enL

EfftttJve .U~ of tetm1Nuon:

number

''"' mMlllfl/1111 _,_ only), 11 (optloNI). 12. and either 1' or 15

Complete all R<tion1

Complete .a R<tions

Complete • R<tions

Complete RCtions 1, 2A. ... '°· 11 (optloMI). and enher 1' °' 15

0 You Vt cNno•llG your Mediare enrollment infonnation o thtl than your tax Go co Section 1 D idenllfiabon nurnbt!r.

Complete all Mdlons

D. WHAT INFORMATION IS CHANGING? Chttk all that apply and complete the required sections.

7 and either 14 or 15 MUST always be anglng within the required Section.

Pl.EASE NOTE: When reporting ANY information, Sections 18, completod In addotlon to completing the information that is ch

CHECK ALL THAT APPLY 0 Current Buslntss Location Information

0 Suppl ler Type (submit licensure if applica ble)

0 Products and Services (submit accreditation if applicable)

D Accreditation Information

0 Address lnlormatlon 0 I 099 Malling Addrt!SS 0 Correspondonce Mailing Addrt!SS D Rt!Yalodation Ma1hng Address D Remitta~ Payment Mailing Address 0 Re<o<d St0<- Address

0 Cornpr...._ U..bilrty Insurance lnfonnation

D Sur"'Y Bond lnfonN1-

0 Authon1ed Offioal

REQUIRED SECTIONS

1, 2, 7, 11(op'liona l),12 (II oppllcoble), and e ither 14 or 15

1, 3, 7. 11 (o pt lonol). 12 (If a ppllcoble), and either 14 or 15

1, 3, 7, 11(optional), 12 (If oppllcnble), and e ither 14 or 15 1. 4 as applicable for the address that is being changed. 7. 11 (optional). 12 (If appllc.oble), and eit~ 14 °' 15.

1, 5, 7. 11 (optlonaO.12, and either 1• or 15

1. 5, 7. 11 (optlonaD, 12. and either 1' Of 15

1. 7. 11 (~ 12. and eitht!r 1' Of 15 1. 7. 8 and/Of 9, ,, (...,.ion.I). 12 (if -liable). - ei!Mr ,. Of 15

1. 7. 10, 11 (optional). and either 1' Of 15

1. 7. 9. 11 (osrt;oNQ. 12. ,. on<! 15

1. 7, 11 (optional). 12 (if appliaible). on<! eitht!r 1' or 15 and the apphcable ttttlon or sulMection that ii <hanQing.

Physicians are not exempt

Land Line (Supplier Standard #9

Physicians are exempt from 30 hour total

Where You Dispense Not the Patient Legal Place of Residence

These are legal definitions

SECTION 3: PRODUCTS/ACCREDITATION INFORMATION

A. TYPE OF SUPPLIER

The •upplier must meet all Medicare requireme nts for the OMEPOS wpploer t~ che<ked Any spedalty -nel including. but not limited to. R"'J>iratory Therapiru and Orthot ics/Prosthetla personnel must ha.., <urrent li«nsure as applicable to the supplier type c:hecl<ed as -II as for 111 l)foduru ind >enricH ched<ed m Sections 3C and 30.

a-It Ill that ewly;

0 AmWatory SurlJ)Cal Center

0 Dei>«trnent St0tt 0 Gtocery StOR 0 Home He.ith AlptC'f 0 HosprtM

0 lndl.,, ~Sevier 0< Tribal Facility 0 lntonnedwte c.e N..w.g Facility 0 Medo! Supply Company 0 Medo! Supply Company

*oth Orthooo ~ 0 Med!Cal Supply Canpany

with Pedorthic ~l 0 Med!Cal Supply Company

with Prosthetla Penonnel 0 MedlCll Supply Company

with Prosthetic and Orthotic Personnel Cl Medkal Supply Company

with Registered Pharmacist 0 Medical Supply Company

with Respiratory Therapist

B. ACCREDITATION INFORMATION

0 Nunmg Fk!lily (othe<l 0 Ocul¥lst 0 O=pauonll Thefapost 0 Opoo... 0 Onho<ics Personnel 0 Oll)'9m and/or Oll)'9m Related E~Suppl1tt

0 Pedonhlc ~I 0 Phannacy 0 Phy>iQI The<opist

0 Phy.lclan 0 Phy.ldan/Oenust 0 Phy.ldan/Optometrlst 0 Prosthetics Per>Ollnel 0 Prosthetic and Orthotk Personnel 0 Rehabllotadon Agency 0 Skilled Nursing Facility 0 Sleep l.4bora tory/Medldne 0 Sports Medicine 0 Other __

NOTE: If more than one accreditation needs to be re ported. copy and complete thl• 1ectlon for each.

Check one of the following and furnish any additional information as requested:

Cl The e nrolling supplier busine.. location in Section 2A is acaedlted.

D The enrolling supplier busine. location in Section 2A is exempt from accreditation requirements.

To determine if you qualify for exemption, go to hnps:/fwww Mlmcttooba mml NSC

C. NON·ACCREDITED PRODUCTS

a-It .U that -1Y. These p<oducts do not requiR acaedir:a.-0 Epoeun Ol~Drug>

0 lnf\.!llOll Orugs 0 Nebulae< Drugs 0 Or.t An1J<M1a< Drug>

0 Or.t Antmnl<tlC Drug> (Replaamem for Intravenous Antlemenc:sl

NOTt; 0 0..0. here if the supplier p<ovides one ot more of the products shown aboYe bu< don not tum.sh M'f of the products and/a< services listed in Section 30. If ched<ed. slup SectJon 30 and tonll~ to Section 4.

Check off all which apply to your practice

Supplier Standard 25 “ All suppliers must disclose upon

enrollment all products and services, including the addition of new product

lines for which they are seeking accreditation.”

State Licensure

•  Requirements Vary from State to State •  15 States Require Licenses for O&P •  Scopes of Practice (SOP) for C. Peds, CPO, CO. •  Pa In Process and Causing Controversy •  Other Professionals SOP DO NOT Limit DPMs

SOP •  NSC Website Home Page “Licensure Database”

SECTION 4: IMPORTANT ADDRESS INFORMATION

A. 1099 MAILING ADDRESS

1. Organlutlonal Supplien (e.g. Corporations, Panner>hips. LlCs, Sub-Chapter S)

If you are an organ1i.ational supplier, furnish the suppliers legal busineu Mme (as reponed to the IRS) and TIN Furnish 1099 rNobng address mformation where indicated. A Cort'/ of the IRS form CP·57S or other document issued by the IRS showing the TIN and LBN for this business MUST be •ubmnted

If you are ~ a change to your 1099 mailing addr- ct..d: the box below and furlldh the effectJ"" date a Cha.nge Effedlve Date (mmlddlyyyyJ: __________ _

l•kl____ ll'riat tu._.,_,._"' __ ,

11099 M:>iing - SUU!

2. Sole PrOl)rletors

If you are a sole proprietor (the only owner of a business that is not Incorporated). lln your Social Security Number ISSN) and the full legal name associated with your SSN as reponed to the IRS In the appropriate fields. If you want your Medicare payments reponed under your Employer Identification Number (EIN) furnish It In the appropriate space below. Furnish 1099 mailing address information where Indicated.

NOTE: Sole Proprietor.: If you furnish an EIN, payment will be made to your EIN. If you do not furnish an EIN. payonent will be made to your SSN. You can not use both a n SSN and EIN. You can only use one number to bill Medi care. If furnishing a n EIN, a copy of the IRS Form CP-575 or other document Issued by the IRS •howlng the EIN and legal name for t his business MUST be submitted.

If you ore reponing a change to your 1099 mailing address, check the box below and furnl•h the effective date.

D Change Effective Date (mm/ddlyyyy): -----------

Sole PrOl)rletors: 1099 M.Hing Address

, .. l .... --...... ""' So<wl s.curity-

'°""'...., _ ...... l _ _ ...,.. •• ""}

1 '(911~-r.Codt·•

CMWSU.frt)) IO

SECTION 4: IMPORTANT ADDRESS INFORMATION (Conrinued)

B. CORRESPO NDENCE MAILING ADDRESS

This Is the ~ross where correspondence will be sent to you by the NSC MAC and/or the DME MAC. OR

D Chedc here If you want all Correspondence mailed to your Business location Address in Section 2A and sic!!> this section

If you are reporting a cnange to yow Correspondence Mailing Ad.ress, check the box below and furnish the effective date

Ette<tl~ Date (mmlddlyyyyl; _ ________ _

--.... ...., __ ,,.o _ ,,,_,,,,_.,,,,_,

1ZIP~ ••

C. REVALIDATIO N REQUEST PACKAGE MAIUNG ADDRESS

Thi> Is the address where the NSC MAC will send your enrollment revalidation request pack49e, OR

D Ch~k here If your Revalidation Request Package should be mailed to your Buslnou Location AcklrHs in Section 2A and slclp this section, OR

Ch eck here ii your Revalidation Request Pack.age should be mailed to your Corrospondence Malling Address In Section 48 and skip this section.

If you are reporting a change to your Revalidation Request Package Mailing Address, check the box below omd furnish the e ffective date.

0 Chonge Effective Date (mm lddlyyyy); -----------

An.tntton (optHNYI}

11

EHR – Where is the Server? Cloud Based?

Supplier Standard 10

Do Not Lie, Alter Facts or Forget to Fill This Out if It Applies No Matter How Many Years Have Passed

SECTION 8: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS)

Only report orgonizations in t his section. Individuals must be reported In ~ion 9. The supplier MUST hove ot least ONE ow ner or controlling entity and ONE managing employee report<-<I In Section 8 and/or Section 9.

Complete th" section with information about all organiiatJOnS that have 5 percent or more (direct or 1ndorect) ownership interest of, any partnership imerest ii\ and/or managing con11ol of, the suppher Identified in Seaions 1 Bl2A. as well as any information on final advene l~I actions that have been Imposed ag.>1nst that org.>n~ation. fo< more information on *direct* and *indirett• ownen and eumples of organ1u1JOns ~ must be report<-<I on this section, go to: https;//www.ans,qoy!MsdiqrtPipyidcrSupEorol!. If there os more than one org.>nizabon with ownership interest or managing <IOntrol, copy and complete this l«1JOn for e<Kh.

OWNERSHIP INTEREST (ORGANIZATIONS)

All org.>na.at>ons that ha... any of the following mun be "'POfted 5 Po<<ent or more direct or indirea ownership of the OM£POS IUllPiCf

• A partMnhlp im..-est in the DMEPOS supplier, regardless of the -n· pe<cen'- of ownenhop • Man19ong control of the DMEPOS sullllliff Owni~ong <><ganizati<lns are generally one of the fol9-inQ typH.

Corpor oboru (l nclud1ng nor>?Ofit corporations) Portnenh1ps end l.anited Partnerships (as indicated above)

IJmited Uob<hty Companies Charitable end/or Religious Organizations Govemmental and/or Tribal Organizations

MANAGING CONTROL (ORGANIZATIONS)

Any organization that exercises operational or managerial control over the OMEPOS supplier, or conducts the day·to-day operations of the OMEPOS supplier, is a managing organlzotlon and must be reported. The organization need not have an ownership interen in the OMEPOS supplier In order to qualify as a managing organization. For example, it could be a ma nagement services organization under contract with the OMEPOS supplier to furnish management services for this business locatlon.

SPECIAL TYPES OF ORGANIZATIONS

Govemmental/Triba l Facilities: If a ~eral, State, county, city o r othe r level of government, the Indian H•alth Servi«• (IHS), or an Indian tribe will be legally and financially responsible for Medicare payments received (including any potontial overpayments), the name of that government, the IHS or Indian tribe mun be roponed as an owner or controlling entity. The DMEPOS supplier must submit a letter on the letterhead of the responsible government -oency or 1t1bal organization that attests that the goyomment O< tnbol organization will be legally and finonoolly ...._,..ble in the e""1lt that there is any outstanding debt owed to CMS. Thk letter must be Signed by an appoint<-<I or elected official of the ~nt or tnbal organlutoon who hos the wthonty to leg.,lly and finanooly bind the government 0< tribal organization to the laws, regulations, and program insttuctions of Medocare. The appo1me<Veleaed official who signed the letter must be reported In Section 9 Indian He.Ith Service or Tribal Facilities: Sc>eoAI rules concemng onswance and ticenses apply. Corna<t the NSC MAC concerntng these ruin. Non-11-ofot. Owuitoble and Religious Organizatiom: Many non-profit~ ace charitable or refogioos m tWD.lfe. and•• -ated end/or manaoed by •Bo.rd of Trusttt< or other governing body. The actual name of the Board of Tru<1tt1 or other~ng body must be reported in this section. While the organaatoon must be reported on s.a-. 8. ondoVldual board IMmben must be reported in Section 9. Ea<h non-ptofit orgaNUIJOft must submit • copy of the IRS Fonn 50 l(c)(l) _,fyfng Its ~ofit status..

IS

SECTION 8: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS) (Continued)

A. ORGANIZATION IDENTIFICATION INFORMATION (OWNERSHIP ANO/OR MANAGING CONTROL)

D Check here If Uus ~ is not applicable for the supplier ~ In Seaiom 18/2A. •nd skip to Se<\Jon 9.

If you •r• <hanging information about a currently reponed owning or m.11nag1n9 OtQOnlZatoon or ..sd1M11 or romoving an owning or managing organization, check the applicable bo., fumlih the effecttvt dote. •nd complete the _ _..te fields in this section.

D a..,. D Add D Remove Effedive Datt (mmlddlyyyyt __

I Complete .a ict~ng .,fonnation below. l.,.. ____ tolho_S-_

._,._,.. . ....._,,,_ --..... ·-------l!Sw~-~·.--1

Nl'l (<f-

2. What Is the abov• organization's ownenliip interest in th• supplier reported In Section IB/2A7 0 S~ or Greater Oirectllndirect Owner 0 Partner D Govemment/Trlbol Owner

3. What Is the effective date the above organization acquired and/or ended the above ownership Interest? D Acquired Effective Date (mmlddlyyyy): --------0 Ended Effectiv• Date (mmlddlyyyy): ---------

4. Wha t Is the above organization's managing control of the supplier reported In Section IB/2A? (Chec:k all that apply) D Managing Organization 0 Board of Trustees 0 Governing Body O Controlling Entity (Gov't/Tribe)

5. What Is the effective date the above organization acquired and/or ended the above managing control? D Acqulrfll Effective Date (mmlddlyyyy): --------0 Ended Effective Date (mmlddlyyyy): ---------

B. FINAL ADVERSE LEGAL ACTION HISTORY

Complete thos section for each organization reported in Se<tion BA..

If you •re reporting a new final adverse legal a ction, check the bo• below and furnish effectlvt dot•. D Now Effmjye Date (mmlddlyyyy): ________ _

I H.. tho organiubon m Section 8A above, t.W>der any anent°' former ,..,,,. or buslneu icknuty, .,_ Md • final adve<w le1jal - listed in Section 1 of this application 1-.I 1911nst it 1 D YES-ContJnue Bdow D NO-Skip to Section 9

2. If YES, report tach ftnal adw<se legal action, when it ocrurred, tho Ftdttlll 0< State agency or the court/ ..wnoncstratrY< bocly thot imposed the action, and the resoMion, if .,.y

Attach • copy of the relevant final adve<se legal action documents.

ANAL ADVERSE LEGAL ACTION DATE TAJCEN BY RESOUITIOH

..

SECTION 9: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS)

Only repon lndivid"8ls in this oection. Organiunions must be reported In Se<tlon 8. The supplier MUST have •t le•st ONE owner or controlling entity and ONE managing employu reported In Section 8 •nd/or Section 9.

NOTE: An lndMd"81 owne< may also be the managing employee to satlsfy this requiremenL

C:O-lete th• section wrth information about all individuals that have S percent or more (direct or ind"'KI) ownership interest of, any partnership interest ir\ and/or managing control of, the supplJer ldenbfled 1n Section> 18/2A. .. _u .. any infonnation on final~ legal actions that h4ve been imposed ag•ir'I"- that lnc!Mdu.l For more .,formation oo "direct" and "indirect" owntt> and~ of 1r>d1Yiduols that must be reported 1n this fieCtJOf\ go to: https;//www~/MedicattProyidnSypEDfPI If there is more than one ondoVKlu.I with ownenhip interest or managing cootrol. copy and complete thll sectoon for eadl

The following tndmcll..lo must be reponed in Section 9A: All pertOnS wf>o h4ve a 5 pe<emt or greater ownenhip (direct or indirect) tnterest tn the DMEPOS s;uppli«r

• All offlctn. dlrtticn ..ld board membe<s if the DMEPOS supplier Is • <OfPO'lllOn (whether for-profit or non-prof rt)

• All maNOtnQ employtts of the OMEPOS supplier • All onc!Mduals with a partnenhip interest. regardless of the -rs· ~ttntllge of ownership, and

All ~~•ted ar>d authonzed offi<ials reponed in Sections 14 ar>d IS £.umple: A supplier rs 100 ~ent owned by Company C. whkh it>elf Is 100 percent owned by lndoVKlu.1 D Assume that Company C is reported in Section 8 as an owner of the supplier Assume further that lndtVldual D ... an indirect owner of the supplier, is reported in Stttion 9A 1. Based on this eumple, the suppler would chedt the ·s Percent or Greater Direct/Indirect Owner" bo• in Stttlon 9A2.

NOTE: All partners W1th1n a partnership must be reported in this appltcatton. This 1pplle• to both 'GeMral" and ·umlted" partner"1ips. For instance, if a limited partnership has several limited partners and each of them only has a I percent interest in the DMEPOS 5'lpplier. each limited partner must be reportod In thl• application, ovon though each owns less than 5 percent. The S percent threshold primarily 1pplle1 to corporations and other organizations that are not partnerships.

For purposes of this application, the terms "officer,• "director,· and "managing employee" oro doflned os follows:

The term 'Offi<er' is defined as any per.;on whose position is listed as being lhot of an offlcor In the OMEPOS supplier's "artkles of incorporation" or "corporate bylaw,_• OR anyone who Is appointed by the board of directors a• an officer in accordance with the DMEPOS supplier's corporate bylaws. The term 'Director• is defined as a member of the DMEPOS 1upplier's 'board of directors.• It does not necessarily lndude a person who may have the word "Director· In his/her job title (e.g • Depertmental Director. Director of Operations). ~term ' M1neginv Employee• means a general manager, buslnfiS manager, admlnl<trat0<, director, or other Individual who exercises operational or managerial control o-. or who directly or indirealy conducu lhe d<oy-to-day operations of the DMEPOS supplier. either under cootrlCt or through'°"'" other 1rr1nge~t. whether or not the individual is a W-2 ernplo)'l'e of the DMEPOS supplier

NOTE: If• 90vemmental or tribal organization will be legally and finanoally r.._,..ble for Medt<Me paymenu rett1ved (per the lllStrUCbons foe GovemmentaVTribal Organoutoons 1n Section 81. the supplier,. only required lO report the appomtedlelected official wf>o ligned the requwed letter l~lly and fononoally btnd.ng the ~rnment/T nbal Organization and its managing employee• In Se<toon 9 Ownen. partners, offictrs, and directors do not need to be reported

"

SECTION 9: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued)

A. INDIVIDUAL IDENTIFlCATION INFORMATION (OWNERSHIP A N D/OR MANAGING CONTIIOU

If you need to re-1, mO<t th.n on• individual. copy and complete this ~ for uch.

If you •re cn•ngong lnformatlon about a currently reponed individual owner « man6Qff « ..idlng or rMIC>Ving .n jnd1111c1.,.1 owner or manager. <heck the applicable bol(, fumhh the effea."" dote, •nd c:omplete the •ppr-.. te 1 .. 1c1s "' th .. Stttion. 0 Chenge 0 Add 0 Remove EH~ Date (mmlddlyyyyt: _____ _

LastNamo Tlr. St. lol D.ot<. -....s. __ _ _ _,,_,,_

Nl'l lif-

2 'l'lhat Is the abo... lndmcluars trtle 1 __________ _

l \Nhat Is the abo... lndmd.,.rs ownership interest in the supplier r._,.ed in Sect'°" 1812A7 0 S~ or GrHter D1re<1Jlndtre<t Owner 0 Partner

4 What Is the efftctl"" date th• abov• individual acquired and/or •nded the above ownership lnt•rest? Acquired Effective Date (mmlddlyyyy): -----------

0 End•d Effective Date (mmlddlyyyyj: -----------

S What Is the above Individual's managing contro l of the supplier reported In Section 1Bl2A7 (Check all that apply). DOffkor D Director

D Contracted Managing Employee Cl W·2 Managing Employee

D Appointed/Elected Official

6. What Is the effective date the above ind ividual acquired and/or ended the above managing control7 Acquired Effective Date (mmlddlyyyy): -----------

0 Ended Effective Date (mmlddlyyyy): -----------

7. ls the above lndlvldual also a Delegated Official or Auth orized Official reponed In Se<tlons 14 or 157 D Delegated Offlclal Cl Authorized Official D Neither

B. FlNAL ADVERSE l£GAL ACTION HISTORY

Complete thlS sectlon for the indMduaJ reported in Section 9A above.

If you .,. reporting • new final ac1ve..,., legal aaion, cne-clt the box below and fumlsh efftctlve dote 0 New Effe<11ve O.te (mmlddlyyyy}: _________ _

Hes the ind.Yldu.I reported 1n Section 9A. under any anent or fonner name or busoness entity. ever heel • flNI adYme ltgal aruon lrsted 11 S«tion 7 of this application imposed agalnst h11Mltrl 0 YES-<ontinue Below 0 NO-Sit.IP to Section 10

2 If Yft. r._,. e.cn fin.I ..iv...,., le90I action. when it occurred, the Fedttal « Sme llQ<n<)I or the C»AJnl edmtMll•Uvt body that imposed the action, and the resolution, if any.

Att..Kll • copy of the relew•nt fina.1 ..tve<se legal action doa.ments.

FINAL AOV£RS( LEGAL ACTlON DATE TAKEN BY AISOltmON

ti

Delegate This

Failure to provide any of the require documents will result in a delay or denial of application

SECTION 13: PENALTIES FOR FALSIFYING INFORMATION ON THIS APPLICATION This section explains the penalties for deliberately furnishing false information In this application to gain or maintain enrollment fn the Mcditare program.

1. 18 U.S.C. § 1001 authorlzos aiminal penalties aga inst an individual who, in any manor within the Jurisdiction of any department or agency of the United States. knowingly and w1ilfully falsifle' conct1l1 or covers up by 1ny trick. sdleme or device a material fact, or makes any false, flctitlou\ or fraudulent n.>temenu or representatio,... or makes any false writing or document knowing the same 10 contain 1ny f1lse, fictitious or fraudu1"1lt ltatement or entry. Individual offenders are subject to fines of up to S250,000 ind impritonment for up to five years.. Offenders that a re organizatJons are subjea 10 fines of up to SS00,000 (18 US .C. § 3571). Semon 3571(d) also authorizes fines of up to~ the g<ou Ill"' ~rlwd by the offender rf it ,. greater than the amount specifically authorized by the sentendng statute

2 Section 11288(.X 1) of the Soaal Security Act authorizes aiminal penalties against any 1nd1\lldual who, ·iu.ow.ng1y and wiUfuly, • makes or causes to be made any false statement or representation o l 1 moterl1I l11ct ., any Apploatoon for•"'! benefit 0< payment under a Federal heahh <Me prognwn The offender i> subject to fines of up to S2S,OOO and/0< imprisonment for up to five ~ars..

3 The CMI Folse O.ms Act, 31 US.C. § 3729, impo5escivil riability, in PM\ on any person who.

1) """"'1ngly present\ or aouses to be presented, to an officer or any ~ of the United States Gowmment 1 false or IT.udulent claim for payment or approval;

bl kno""ngly make\ -.. or aouses to be made or used. a fals<o record 0< SUteiMM 10 get 1 f.ise or fr .udu~nt claim paid 0< ._.<Med by the Go""'1VllEflt; or

<) conspres to defr.ud the Gow~t by getting a false or fraudulent dalm allowed or paid The Act imposes a ckr1I penalty of SS,000 to S 10,000 per violation, plus dvtt omes the amount of damage> sustained by the ~t

4 Section 1128A(aX 1) of the Social Secunty Act impcnes civil liability, on pan. on any person (1ndud1ng on org1niutlon, agency or other entity) that knowingly presents or causes to be presented 10 an officer, employee, Of' agent of the Unrted States. or of any department or agency thereof, or of any St6te agency ... a daim ... that the Secretary determines is for a medical or other item or ~M~ that the person knowt or should know: a) was not provided as claimed; and/or b) the claim Is false or fraudulent.

This provision authorizes a civil monetary penalty of up to S 10,000 for each Item or service, on assessment o f up to three times the 1?1mount claimed, and exclusion from participation in the MedlCllre program and Sta te health care programs.

5. 18 U.S.C. 1035 authorizes criminal pena lties aga inst individuals in any matter Involving a health care bene fit program who kno wingly and willfully falsifies, conceals o r covers up by any trick, schem e, or dovlce a materlal feet; or makes any materially fa lse, fictitious, or fraudulent statemen·ts or representat lon1, o r make-s or uses any materially false fictitious, or fra u dulent statement or entry, In connection with the delivery of or payment for health care benefits, items or services. The Individual shall be lln"d or Imprisoned up to S years or both.

6. 18 U.S C. 1347 authorizes aiminal penalties against individuals who knowing and willfully execute, or 1nempt, to executive a sdleme or artifice to delTaud any health care ben.,flt program, or 10 obtoll\ by mHns ol f1lse or ITaudulent pretenses, representations, 0< prom~1, a ny of the money or property owned by or under the control of any, health care benefit program in conntttlon with the dehv~ of 0< paymerit for he1lth are benefiU. items,. or semces. Individuals shall be fined or imprisoned up to 10 ~•rs or both. II the VIOl1llon resulu on senous bodily injury, an individual wiR be fined 0< Imprisoned up to 20 ~·,... 0< both 11 the vlol1toon results m dealt\ the individual shaU be fined or imprllOned for any term of ye41rs or for hit, or both

7 The gowmment IM)'....,rt common law claims such as •common law fraud.· •money paid by rnlStlkt." and "unjust ., o ldln ~ 1t. •

Rerntd1es include -tO<Y ..1d punitive damage,,. restitution, and recovery of the amount of the UnfUSI prof rt.

II

SECTION 14: ASSIGNMENT OF DELEGATED OFFICIAL(S) (Opt ional)

A DELEGATED OfflCIAl means an individual who is delegated the authority to rtl>Oft changM and updatM to tht oupploer's el\l'ollment record by an authorized official. The delegated official must be an lndtvldual with "ownenhlp or convol inttrtst in" (as that term is defined in ~aion I 124(a)(3) of tht Soci•I ~wr1ty Act) or be • W-2 man•glng emplo~e of the supptie.-. An independent contractor Is not considered employed by the supplle< and therefore cannot be a delegated official.

O.leg1ted offlc:.Mlls m•y not delegate their a uthority to any other indMdual Only an authonzed officMll may deleg.te the ..,thonty to make changes and/or updates to the <upplitr's Mediate e<Vollmtnt .,formatlon Even when deleg.ted officak - reported in this a pplication, the authonttd offlOll "''"""the authonty to mae cNtlges and/CK updates.

You •rt not rt<IU•ed to have a delegated official However. if no delegated offtOal is nsogntd, the authonttd offlcul(s) ""'' be the only penon(s) who can make changes and/or updatM to the enrollment 1nformat>on

The "llf"'tl#e of a delegated offici.11 shal have the same foroe and efft<t as that of an authonzed offooal, and shall leg.ly and finanoaly bmd the ~ier to the laws, "'9Ulauons. and progrMn lnstru<t--.s of the Medtart program. By hd or her signature, a delegated official certifies !hat he or sl>t has read the ~ ... f0< hlsofytng lnformauon 1n s..ctJon 13 and the Catification Statement in~- ISA and agrees to adhere to an of the stated requnrnenu. The delegated official also ce<ttfies !hat heliht rnttts the deflflit.,., of • delegated off>e,.L When malong changes and/or updates to the suppll<f's e<Volimtnt inlormat>on, the dele~ted off>eill ctrtrf>es lhat the infonnation provided is true, CO<rt<t and complete

The "gnatwe of an -'-<ted official in Section 14 constitutes a legal delegauon of autho<lty to 111 dele~ted off>e1al(s) asstgned in Section 14. If you are delegating mott than two indnliduals, COl>Y and complete tlus section for eadl addrtional delegated individual

NOTE: A delegated official who is being re.-noved does not have to •ign or date this appllcotJon

ASSIGNMENT OF DELEGATED OFFICIAL

All Del09attd Officials must be reported in Section 9 of this application.

If you art adding or removing a delegated official, check the applicoble box and furnish the e ffective date.

1" Del09ated Offld al's Name and Signature

0 Add 0 Remove Effective Date (mm/ddlyyyy): -----------Undor ponalty o f 1>4rjury, I, tho undersignod, certify that I have read and undorstand tho C..rtlflcatlon Statomonl In Soctlon 1 SA end a ccopt tho rolo of Dologatod Official. Otltt•ttd Oflk'ltl Finl Nam• {PnntJ MiddJe Initial Last Name (PrlnO Jf .Sr.., MD,ttc

o.l991tff Otfldll ~n1tutt {F11Tf. MHJdle. List N~ Jr .. Sr.,. M.D .. ete..}

E-<nail -(d _,iQbHJ

2"' 0ele9ated Off'tcial's N&me ond Signature 0 Add 0 Rt..-e ~Dale (mmlddlyyyyj: ________ _

Undot l*\lhy of pequry, l llM w d@sigiK!d. cel1ify that I haw rHd ond understand lht Ctrtlftutlon SIA- t In Section t SA ond _. llM roi. of l>@logoU!d Official

22

SECTION 1S: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE An AUTHORIZED OFFICIAL means an appointed officia l (for example, chief executive officer, chief financial officer, general partner. chairman of the board, or 5~ or greater direct owner) to whom the organlut lon has gronted the legal authorrty to enroll it in the Medic.are program, to make changes or updat .. to the organ1utlon's enrollment Information in the Medicare program, and to commn the organization to fully oblde by the st1tutts, regulattans, and program instructions of the Medicare program.

By his/her signature, an authorized official b!llds the supplier to an of the ttqulrements listed In the Ceruficltlon Stotement Ind adcnowtedges that the supplier may be denied Mtty to or have rts bllllno priY1leges revoked from the Medicare program if any requirements""' not met. All 5'gnlltures must be orlgln1I ind ., bM rnk. Faxed, photooopied, or sta.mped signatures Wtft not be accepted

By SIQNng this 1pplie1toon, an iMlthonzed official agrees to immediately notify the NSC MAC rf .ny .,formo,_., tn this -Ila-. "not 1rue. correct. or complete. In additkMi, an authorized offrct1l by hW her 51gn1tun, IO'ttS to notify the NSC MAC of any fut1.n changes to the informo,_., cont1rned on this opplraUon •fttt the ~ "e.rvolled in Medicare, within 30 days of the efferove dote of the ~

ApplaUons Aibmrtted for onru.i enrollment must be signed by an Authoriud <>trio.I or they Wll be rei«ted Ind returned unprocessed.

~ cenrf!ution below rndudes addrtJonal requi.ements that the .._iier mun meet Ind m.1nt1., t o blll the Medt<Me pr09t1m Reid thew requuements ca<efully. By signing, you are anesuno to ha"'no reld the reqwrements Ind underslandll'IQ 1hem.

Your "ONJl\lre ~ stipulates U..t you agree to adhe<e to al of the requirements lrsted below and ..:ltnowl_. thlt you may be denied entry mto or have yocw bilfing P<Mleoes revolced from the Medrcare prog:r•m 1f any requi~m~ts Me not mfi.

A. CERTIFICATION STATEMENT

You MUST SIGN AND DATE Section 158 of this certification statement to become enrolled In the Medi<ore program. In doing so. you are attt:stmg to meeting and maintaining the M•di<ar• requirements st1tf:d below Under penalty of perjury, l the undersi11ned, certify to the following: 1. I have read the contenu of this application. and the information contained herein is true. COf'rect and

complete. If I become aware that any information in this application is not true, correct, or complete, I •or .. to notify the NSC MAC of this fact immediately.

2. I agree to no tify the NSC MAC of any current or future changes to the Information contained In this application In a ccordance with the t imeframes established in 42 CFR § 424.57, I understand tha t any change In the business s tructure o f this supplier may require the submission of a new appllcatlon.

3. I have read and understand the Penalties for Falsifying Information, as printed In this application. I understand that eny deliberate omission. misrepresentation. or falsification of any Information contained In this application or contain~ in a ny communication supptying information to Medicare, or any deliberate alteration of any text on this application form, may be punished by criminal, clvrl, or administrative penalties Including. but not limited to, the denial or revocation of Medicare Identification numberb), 1nc:Uor tM lmposttion of fin~ dvil damages, and/or imprisonment..

4. I agree to •bide by the Social St:Writy Act and a ll applicable Medicare la ws, regulauons end program Instructions that opply to th" supplier. The Medicare laws, regulations, and progrom lnstl'Uctlons ire •••tlable through thf: MedKare contractor. I understand that payment of a claim by Medi<are" condttioned upon the da1m and the underlying transaction complying with such I"""- regul1t rons, Ind prog11m rnstNctt<>m (rndudrno, but not !united to, the Federal anti-lodcbadt Stltute M>d the Stork 1-). ind on the "'1>Pi1er's cornplt1n« with all applicable conditions of participation •n Medure

5 Nenher tlvs supplier, nor any fr.,, percent°' greater owner, -r. officer. dirf:ctor. manogono ernploytt, d.._ted of~ or IUthonz~ official thereof is currently sanctioned, ..._nded, deborred, or excluded by Mf:dicwe or M'IY St1te Health C..,,, Program (e'}.. Medicaid program), or any other Fedtr1I pr09f.,,,, or is otherwise prol\fblted from supplying services to Medicare or other Ff:deral ~m beMf10111es.

(; I IQltt U..t M'IY el<dlJn9 or fut11e """'J>ayment made to the~ by the Mtdoa<e pr09t1m ""'Y bf: recouped by MedlCl<e through the wrthholding of fuwre paymems.

7. I Wlil not knowlngly present or~ to be !l'esented a false 0< fraudu~nt datm for p,tyment by MedocMe, ind w~I not Aibmrt dawns Wllh deliberate ignorance or rectJess disttgard of their truth or lllS<ty

8 I IUthorue 1ny n1t1onal ao:r~rtJng body whose standards are remgnae<I by the SecretMy os meetJno the MedtU<e program paruop,ttJon ttQUWf:lllelts, to release to any authorized ,_....,.,.tiw, em~•. or •oent of Medoclre • ClOPY of my most rf:Cent accreditation surwy, together with any .,form.trc.. rol•ted to the surwy !hat Medare may rejUire (including corrective action plans).

n

SECTION 15: AUTHORIZED OFFICIAL CERTIFICATION STATEMENT AND SIGNATURE (Conrlnued)

8. AUTHORIZED OFFICIAL SIGNATURE(S) All Authorized Officials must be reported in Section 9 of this application. If you ue .dd1ng or removing an Authorized Official, check the applicable box and furnish the effective date

1• Authorized Offkllll I have re.cl the content• of this applic.ation and the certificanon statement in~ 1SA of th .. applk41tion My llgn<lture reo.i1y and finanoally bonds this supplie r to the laws, regulatJOm, and pr-am 1nstructk>nl of w !Md.are program. By my ggnan.e, I unify that the information contalntd ~e1n Is true, <MK!.. and complete, M>d I aut'-'ze the NSC MAC to Vl?"rify this infonnation.

1• Authorued Offklllr• lnformwon and ~ D Add 0 Rernow Effe<tMe Date (mmldd/yyyyj';

-·-All •IQNWre mun bo origin.JI ~ signed in blue ink. Applbtiom wi1h sign.>tW9• - not OflglNI

or not d.ltad wfl not bo pn>c...ad. Sumped. faxed or copied lignotum will not bo xcapWd.

2"" Authorized Official I have read the contents of thi• application and the certification statement In Section 15A of thl• appllutlon My llgnature legally and frnancially binds this supplie r to the laws, regulations, and program Instruction• of the Medicare prOQram By my signature. I certify that the informat ion contained herein Is true, corrttt, ind comp le to, and I authorize the NSC MAC to ve rify this information.

2"" Authorized Official's Information and Signature D Add D Remove Effective Date (mmlddlyyyy):

Finl N1m11 (Pt nt> Middle Initial l ast Name (Print) II ,. 51 , M.O, t lC.

1.ttphont Numbfi E-m.ad Address (;f applic.able) TitlelPowllon

All slgnotum must bo orlgl~I •nd sigRQCI in blue ink. Applicatiom with •lg~tures dMmad not orlgtnol or not d.ltad wil not bo pn>c...ad. Sumped. faxed a< copied slg~tures will not bo actaplod.

l"' Authorittd OffKial I haYe re.cl the contents of ttus application and the certification statement in Section 15A of thi• appbation My MQnatlKt ieo.11y and finanoally bonds this supplier to the laws, regulatiom, and pr-am lmtrU<tlOnl of the MedKMt -•m. By my signatU<e, I certify that the information contained herein a tru•, CMKI.. and complete, and I aut'-'ze the NSC MAC to verify this infonnation.

r Authorued Official'• Information ....i Signature D Add D Remoft Effe<tMe Date (mmld<fl1yyyt;

-- Lost---·-All sl;NtUm mun bo origin.JI ~ signed In blue int. Applicatlom wi1h lignoturH - not orlQlr>ol

or not d.llad wl1 not bo proceswd. Sumped. faxod or copied lignotum will not bo auapt..i.

CMS.m\11 covn>

DCPAAl~lNr or Jl[ALfU AHO MUMAN U IMCH aNr~"!S ro" Mla.cN!l I MfOtCAID UINl(tS

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT lht Autho<lty for malnttrnin<t of tho systom is given under provisions o f sectlons 1102(0) mtlt 42 U S.C 1302(1)), 1128 (42 U.S.C 13200-7), 1814(1)) (42 U.S.C. 139Sf(a)(1), 181S(al (42 U.S.C. 139'5g(a)), 1833(t) (42 U S.C 13951(3)), 1871 (42 U S.C. 1395hhl, end 1886(d)(S}(f), (42 U.S.C. B9Sww(d)(SXFl of tho SOcial S4KU<lty Act, 1842(t) (42 U.S C. 139Su(r)), 1«1Jon 1124(4)(1) (42 U S.C. 132Ga-l(a)(1), and 1124A (42 U.S.C. 132Ga-3o), s.<tion 431), 1s arTMndld, of tho 88A of 1997, and section 31001ro 01 u.s.c. nol) of the OCIA <Pub. L 104-134), es am.ndld TIM 1nfonn1uon coli.cted hart will be onn>rod into the Provider Enrollment. Chain Ind Own..-shlp Systtm !PECOSI P{COS will collect lnfOf'INuon P<ovldod ~an apptocarn rolated to identity, qual.ticatJOn$, pr..,_ loatoom, -.h•p, bdhng 11JOOCf lnfonnatlon. roaWgnrnEm of 00..fits. electronic funds VM>Sfer, tho NPI ond rolotld Of91NZ•tlOnS P{COS w•ll 1lso "'°'ntllll infonnation on business owners. <Nin homo officM ond provldo<ldll•n OllOdlbonS, ma~ dnctlno .....,,ee~ panners, authori2ed and dek!gatod offlOlls. .._,.._ phyMclins of tho iupp1..,, ombuloru voNd<o infonnatlon. andlor intgpromg physidilns Ind ~ tochNoons lhn synom of roa>rds .,.;a conU111 tho norM$o social SO<Urity runbers (SSH), date of binh (008), ond omj)loy« ldenbflat>on numbon ([IN) and NPl's lo< tad\ dlsdmlng entity, owners with S percent or 11IOA ~ 0< Cl0'1trol 1nter0<t, es well es ~dlrecmg employ-. M>~ecting snpiayees include _... manoger, bU1lnt1& -odnwvruot~ dlroa~ Ind ...i- lndMduals who ae-cise opera-..1 or......_,., O>ntrOI ...., tho provldo<I suppt..,. Tho sys1Mn w I 1lso COflUJtl Mediate kkmilicatico numbon 0.o. CCII, PT AH 1nd tho NPO, domo!lr6PllK dai., pn>fosMOnll dai.. post end presom history as well as inlcnnation regording ...., ..tverM legol 1<11ons wen 11 txdullons. soncuons, Ind felonious l»havlor.

Tho Pnvocy Act permits CMS to difdose Information wfthout an individuats c- if the lnfOf'INuon ll to be uwd lo.- 1 purpolO !hit Is <>0mPltlblt wi1h me purposoW for which the information wos a>l14<11d ,.,.., such dhdosuro of doi. ls known 11 1 •rouono USt • Th& CMS wiU only release PECOS information that <An be 11sodltod With 1n lndlvlduol as provided f0< undor Section DI "Proposed Routine Use O!Sdow:res of Dato In tho Systtm • 8oth ldenttf11bl• and non-ldontlfi.blo date may bE disclosed under a routine use. CMS will only colltct tht mlnjmum pononol dot• nocosllf)' to ad>ltvo tho purpose of PECOS. Below is an abbrevi<ltod wmmary of tht six routine uMH To vlow the routine u5'n In tha1r entirety go t o: http://www.cms.oov/RequJ1ttonandGytdonc1tGutd1nct{ PdyocyA<1Svs1tm0f8tcords!c!ow nloads/OS32.pdf_

1 To supPO<t CMS contractors, consultants, or grantees, who have been ongagod by CMS to assist In tht performance of 1 service related to this collection and who need to have accoll to tht rocords In ordor to perform tho actlVlty. To llHln anothor Federal or state agency. agency of a state government or tts fi s<bl agent to:

ft . Contribute to tho accuracy of CMS's p roper payment of Medicare benefits, b. Enablo such agency to administer a federal health benefits program thot lmplomtnts e hoelth btnoflu

program fundod In wholo or In part w ith fodoral funds, and/or c. Evaluato and monitor tho quality of homo health care and contributo to tho atcuracy o f hoolth lnsuron<o

operations. 3 To onlst on Individual or organization for research, evaluation or epidomiologlcol projtcU rolatod to tho

pr1venllon of dlsuw or dlsabllrty, or the restoration or maintenance of health. and for paymient related projtcU

4 To support tht O.partmtnt of Junko (OOJ), court or adjudkatory body when; o Tht agency or any component thoreof, or b Any omployet of tht agency In ht. or her official capacity, °' cc Any omployet of tht agoncy In ht. or her individual capacity where tho OOJ ha• egrHd to roprtsont tho

employee,°' d Tho United States Gow<rvntnt. Is a pany to litigation and that the use of sudl rtcorch ~ tlM 001, coun or

odjudocatory body i. cz>me>a1lble with the purpose for which CMS coll@ctod tho rtcorch S lo llSlst 1 CMS contra<tor that a<Slsu In the administration of a CMS admonm..-od hoolth benofrts PfOQf.,,,, 0<

to combat ft1ud, w..i., or 1busa In !UCh program. 6 To - onodlo< ~I agency to lnwstigate potential fraud. waste. or •buse in. 1 Mlhh benof1u prOQrlm

lundod 1n whole or In Pon by kd«al funds.

Tho 1ppljunt lhould be aware that tho Comput0< Matching and Privacy ProtiKtJOn Act of 1988 Cl' L 100.SOJ) lmended tho PrMKy Aa, 5 U.S.C. § SS2o. to permit the government to vonly lnformat>on dvough­matctw.Q

Acmrd1'910 tN ,.,~ ~ N.f. of 199§..., perm ilre requinod co respood to.~ of~ .. ..,.,._"......,., • ....... ()Ml COl'lt'OI """*"' The ...w Ola mnuol ~for di& intormallCm ~. 09.Jl..1'1S6.. n. """" ,......... &o a:wnpllil• .. ""~ IDOilenlOn a~ lO be:' houri p« teipClftSi!. inckdiog the UM SO~~ Mll"d\ _,.,,,,., ~ ~ V-'* ft d#\.1 Medlll llftd COlftSlill't• #Id rwww !M tnfonnation c~ If rou haw ""F~ ~ 1N .crut"M'f °' tN ._ _t<>I •-... _""' -p1 .... - ro:CMS. ~So<unl7-.-d.""" _._,.Cit•-*~-. ... ._ .. ~111Mlfi0 DO NOT MAil APNCATIOHS TO 1MS ADDIESS. M.;i;.g your appioation to this-.,..,... MgNI,._,, _, __ oro<--0

Cheat Sheet on Completing the C~fS-855$

h at UllpOl'Wll 10 ttad lbt uutrucnous that art included wilh eacl:a Sttrion throupout !he appbe1t10D form If you WI 10 comp~tt lbt appb<1nao proptrly. pro<e$$U>! llJDe will lib ly bt delayed silre ,.,. will thon .....i to de\'elop !he appbunoD \1& phont and or wnttt11 \"ahcUbOD. dtpolldmg oa l\'hat DO<di to bt eoJI4>ltted. Do not""' p .. cil OD rhr OIS.S5$S (011n .~ppl1nnont rhr ••t fit/I'll o•r m pninl ••II 01 "I"'' •trh • rwbbn- """'P• copf or ilf pma1 ,.-ii/ pro.,pdJ' br ' """""' •• •01,,.ormobl•" Tbt CMS-USS form" a ~gal clocumtal md mmt b. l>Nted .. such. Read mh section arefu!Jy ml..,.,...,. thoroqghly Tbm art 1...,.,rt1n1di«iboxes111 tacli ote:llOD tha! maybttasalymwecl Below you will fiDdsome rips ID bolpmg)'Oll to oompk'lt lbt CMS-USS l!)'OU ha\'e uy qllf<IXml. ~ call tbt toll fltt jl,)C c-. Senice Ce=< .. 1-866-23&.96.H F..t fr«< to ollo "'°""" ~ cht ::O."SC """ Utt b uWmiwioa (,.,.,.. ~O(b&.c:om ~ chck"" ~Other PartDBS ac l'm\*n ~ wl«t ::.'ano.W ~ ~)

Tbt CMS-IUS fona 1110 bt med for eun>llmem of• °""'" D)JE?()S "'PPM ll!!!rber. "'~DI. rtae11\"ll>Oll. mroU..... of a ...,.­..,._for a cmncdy ~ Sllppba:. chmg< ofin!mmrion. am~ 1mllllOOD of a bilWla aumbtr Pltaw mad die <btd: beat ~ tbt ......., 6't wllach f""""' filling oat !be fmm i!l ..men I "" po~ S

XOTF: A"'°"'h tM &SSS 111dia1:.1> dlGl o "'1'¢cr Im 90 <h}-. "' ullll a ""J" r""'zo cf~- dw: I ~ s-.lorC ..U fl'W-'-• "'., tM ~fora i'ttwc c.,.,p/prolt s-a-11'1 b) sntt!mz c1-p <(,,.,,,_r- "idibt JO"->• of dw <'-:• FOR AU. E:'"ROLUJL\l'S. R.E-DlWl.U.II:XTS, A..\"D RE-.\ClffA TIO'.'\S: U~o• art~: Complere sttcions:

L 2. 3. 4. 5A, 6. 8- 13. 15. 16, 17 - md 1t<t10D I~ carttlally BUUD<UIPtol!wooo11.amil<d wbwry Co 11100

L 2. 3. 4. 5B-5C, 6. 8, 13, 15, 16, 17 - "'ad stc:llCO I~ Cattlldly

Otnttal Por11ltt OR JOUll V...iun L 2. 3, 4, 5A OR 5B-5C (•Hpp~). 6, a, 13, I~. 16, 17 - .-.... ...,-lt<ll--OD-14_c_art_full_lly _ _,

Plu,. nott 1b>1 sumy bonds an 001 rrqu.irnL S.ction 11 "S11ttry Bond IofornurioD" 11uy b• ltfl blouk on all appllurio.,.

FOR ALL CHANCES TO YOUR SUPPLIER ffiI: Stltcl ''Chang• oflnformation• in oection 1.AJ, mark the sections (boxes 1 - 16) 1lu1 you ore cb.~ngmg, and wnl• your suppbtr nuwb<r an die blonl: opoce besadt O>t change option. Then in the section(s) where changts art bting mAM, mark the "Chang• .. cbtck oox al lh< lop or toch stcliou and complel• the section. The appropriate authorized or d.legat<d offiml mu:tr sign Jtcllon IS (Ce11>6carion Siot•nitlll) Send the compltled sections and any applicable attachments 10 rhe NSC at 1he oddr"s an 1he fron1 of the opplic111on form.

FOR \ 'OLl'NTARY T£R:\11J\ATION OF DMEPOS BILLING NID!BER: Stltcl ''Vol11D1arr Termuution" in ...:hon LA.1. and \\Tite your supplier nnmbtr in~ blank space btsidt "Change of btformauon·· ngbt above tht \'Oluntalj' tenmnario.D ch«k box. Enter tht date of tennination. Fill out stc:non l .A and 4 A fo11dt1111f1c1nou of suppbtr &Dd loc1bon Only the aulhonzl.d (Dot dtl•g1ted) official can s.ign section 15 (Cerofiunon Suntm<Dl) of a Voluntll)' Ttrmuiabon foam.

DO NOT iatlud• •h• follo1'ia.g: Cfh• xsc dots DOI do uything mrh rlili p•p••.,...rk aad h It DOI rtqoirtd.) Fot m HCF."-5SS mtttionrd undu sntion 4.C. Tbt [DI toa1racr tlaac is Dtt.Adontd in stttio.n 9. Pltast do nor ('ODl'ltl yoar DllERC 10 adt for dtl.s paptrn'Ork.

f11al C bu14iu D Im-. )'OU co..p...d rbr oppn>pD1Z S«llaDS? tJ Ha\ .. )'OU tappbed .u llfllltOPIW• an:ochmeJm? (C'becl; secllOJl 17) 0 Ha\-. )'OU 111tlllded ~.ml ED'• .. il<R ~ .J Did>- ,..ruy dioi tilt fono.w.g addresses u. KOT P.O. bmrs: S.C""" 4A - llmlDrts Locanoa. Stctio.. JD - 1.ocoDa of po1><m

RCOnk. S«uon SB - Btllmi! Apac)- ,J.dihss~ o Did )'OU "'11 ~ U (llo """'P-pencil or pbomcopy signa=)? An die~ tboot o( pmoas ,.i.. art audlonz.d IO up('

Ataptalilt Au:bonzed Offiaal (mly I ?"' mtity'u.x Oaner, o-n! Pma>os-. Cbinmn of the Board. Pt.sad.ml. CEO. COO CFO. ID • - lllllloon:itd ol5aal 11 ..,, locabGD speafic.) or """' !:old a "°"""" of mmJ.ar wan and lllllloril)· A<ttpubW ~p:.d Offiaal (up to 3 ?"' .m.;· Ill M•u:a~ Employot {gtttral mmagu. busmeu .,..,.,.. Admmum1«. ac ID• -dtwp~ oflicW .. not LxaboD spea&. If 1111 someone \\ilo """"'" opennonal"' llWllltlUI CODIJOI O\'tr die <ompaDy) ••ftl) tus.lla to add - a1"i a/nad} 1"" tltrtt, i1 """' Proof of emp!o~m may be requutd This ofrit.w -Y abo be an h.dmdftl 'Oh1<11oftltoftm dltw rod•lEte.) indi\iduaJ \\ilo holds S" o or mort dmct OWlltnlup Ullt rtsl ID lbt COmpoDy

These indi\'iduili will bt hsttd ID lt<llOD 6

Where Can I Obtain an Application?

http://www.palmettogba.com/nsc

. .... - .... ego ~~.~~;G:~?co~P~N~· - , ____ . ~~

'i'!''1'-!·!!;1•1t1=••·1•m••1t•1 MW,,M1n•t- , •• ,,,'d'i'i'!'M

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Online enrollment is now available for all OMEPOS suppli ers! The Provider Enrollment Chain Ownership System

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CONTACT INFORMATION

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IVR: (866) 238·9652 Address National Supplier Clearinghouse

Palmetto GBA, AG-495 P.O. Box 100142 Columbia, SC 29202·3142

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Clearinghouse to have your inquiries answered. Please do

not include Protected Heath Information .

<l> 2014 PALMETTO GBA, LLC. I GET ADOBE RE~DER I GET MICROSOFT EXCEL VIEWER I PRIVACY POLICY I SITE HELP I SITE MAP

What Else Do I Need?

https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS588.pdf

OC:PAR:TMCNt oi: MWtM ANO MUMA.N SERVICES GHTER.S FOR MEDICARE & MEDICAJD SERVICES

r«mApptcwtd OMB No. 0933-0626

ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT PART I: REASON FOR SUBMISSION

Reason for Submission: 0 New EFT Enrollment 0 Change to Current EFT Enro llment

(e.g. ac:count or bank changes) 0 Cancel EFT Enrollment

0 Check here if EFT payment is being made to the Home Office of Chain (Attach letter Authorizing EFT payment to Chain Homo Offko)

Since your last EFT authorization agreelll'lent submission, have you had a:

0 Change o f Ownership, and/or D Change of Practice locat ion?

If you checked elthM a change of ownerslnlp or change of practka locatlon above. you must submit a change of information (using the! Medicare f:!nrollme>nt applkation) to the Medicare contractor that services your geographical area(s) prior to or accompanying this EFT authori:z_ation agreement submission.

PART II: ACCOUNT HOLDER INFORMATION ProvidtrlSuppUtrllndirtct P1ymen1 Procedure (IPP; Biller ltgi l Busin•u Ntmt

Chi in Orgiilniu tion Nime Of Home Offic;e Ltgiill BWneou Nilffle (if d ifferent from Chi in Orgi niziilt ion Ni me)

Account Holder's Practice Loc.alion Street Address

Acc;ount Holder's Practice Loc.alion City I A.ccount Holder's Practice Locat ion State I Account Hokle-r's Practice Location Zip Code

ooocaooo'oooooo"NI lodoo'o'oooo'oo DD Health Plan Identifier (HPIO) or Other Entity Identifier (OEID) (IPP Entities Only)

DODD DD DD DD 0'0'0°"0'000000 lo'o'ffD'oo'2iooo lo'o'ffD'oooooo PART Ill: FINANCIAL INSTITUTION INFORMATION Fln1nc11l IMtltuti0n's Nam•

Fln1nc11l lniUt uUon'1 StrHt Addrt'n

Fin1nci1l ln1titution's City/Town fin1n<ii l Institution'• StitelProvince

Financial lrn:t itution's Telephone Number Financial Institution's Contact Penon

Financial Inst itut ion Routing Number

DDDDDDDDD

Please include a confirmation of account information on bank letterhead or a voided check. When submitting the dorum!ntatlon, It should contain the na~ on the account, electronic rout ing transit number, account number and type. If submitting bank letterhead, the bank officer's name and signature is also required. This information will be used to verify your account number.

PLEASE NOTE: In accordance with section 1104 of the Affordable Care Act, enrollment o f electronic fund t ransfer (EFD is for electronic fund transfer authorization only. EFT enro llment does not constitute enrollment as a provider o r supplier in the Medicare program.

-PART IV: CONTACT PERSO N Contact Penon"s Name Contact Penon's Title

Contact Penon's litlephone Nurnt»r Cont.act P.rson's E-mail Address

PART V: AUTHORIZATION

I hereby authorize the Centers for Medicare & Medicaid Services (CMS) to initiate credit entries, and in accordance with 31 CFR part 210.6(1) initlat• adjust,,,.nts for any dupliC.!Jte ot erronoous ontries made In errot to the account indicated above. I hereby authorize the financial institution/bank named above to credit and.tor debit the same to such account. CMS may assign its rights and obligations under this agreement to CMS' designated fee-for-service contractor. CMS may change its designated contractor at CMS' d iscretion.

If payment is being made to an account controlled by a Chain Home Office. t he Provider of Services hereby acknowledges that payment to the Olain Office under these circumstances is still considered payment to the Provider, and the Provldor authorizes th• forwarding of MediC.!Jro paym•nts to tho Chain Home Office.

If the account is drawn in the Physician's or Individual Practrtioner's Name, o r the legal Busin~ Name of the Provider/Supplior ot IPP •ntity, th• said Providor/Supplier ot IPP entity cortifi•s that ho/she has sole control of the account referenced above, and certifios that all arrangemonts between the Financial Institution and tho said Provid er/Supplier or IPP entity are in accordance with all applicable Med icare regulations and instructions.

This authorization agreement is effective as of the signature daite below and is to remain in full force and effec.1 until CMS has received writte n notification from m e of its termination in such time and such manner as to afford CMS and the Financial Institution a reasonable opportunity to ac.1 on it. CMS will continue to send the d irect depo<it to the Financial Institution indiC.!Jted above until notified by me that I wish to change th• Financial Institution receiving the direct deposit. If my Financial Institution information change~ I agree to submit to CMS an updated EFT Authorization Agreement.

SIGNATURE LINE

AuthoriledlOelegated Offic:ia l Name (Print) AuthoritedlOelegated Officia l Telephone Number

AuthonzedlDelegated Officia l title AuthonzedlDelegated Officia l E-majl Address

AuthorizedlD.&.gatad Offic:Lat Signaturw (Nor.: Must IN °"9i"MI sign1iu,. in bl•d: or blu. Ink..) I° ... PRIVACY ACT ADVISORY STATEMENT

Sections 1842, 1862(b) and 1874 of t itle XVIII of the Social Security Act authorize t he collection of this information. TM purpose of collecting this information is to authorize e:l~ctronlc funds transfe:rs~

Per 42 CFR 424.Sl ()(e)(l), providers and suppliers are requirod to receiv• electronic funds transfer <Em at the time of enrollment. revalidation, change of MediC.!Jre contractors ot submission of an enrollment chang• request; and (2) submit the CMS-588 form to receive Medicare payment via e lectronic funds transfer.

The information collected will be entered into system No. 09-70-0501, titled ·carrier MediC.!Jre Claims Recotds, • and No. 09-70-0S03, titled 'Intermediary Medic<>re Cla ims Recotds' publishod in the Federal Register Privacy Act Issuances. 1991 Comp. Vol. 1, pages 419 and 424, or as updat ed and republished. Disclosures of information from this system can be found In this notice.

You should be aware that P_L. 100-503, the Computer Matching and Pnvacy Protection Act of 1988, permits the governm•nt. undor certain circumstances, to verify tho infotmatlon you provide by way of computer matches.

According to the ~pwwort hduction Act of 19K, no S*JOfS ar• r-.quir~ to rnpond to 1 c;oltection of inform1tion unku it dispt.ys a valid OMB control number. The valid OMB control number for thK infonnation collection is 0938-0626. The time r@qUiR"d to comple-te this information colec.tJOn 6 estimatlld to aver-age &0 m inutes per re~. including t he t ime to rev.tw mstrutbOns,, searc;h Hirt.Ing d at.J rnource:1, gath9t" the data nNd•d. ind oomplH• and r....WW tM inform•tion c;ohction. tt you~ any conwnt:nu «MKflning tM KC:UrKY of Che time estimate(s) o r suggestions for improving th& fOITT\ please write to: CMS, Attn: PRA Reports Clea~aa Officer, 7~ Securrt)' 8ouJevard. 8alllm0ft, Marytand 21244-1850.

DO NOT MAil THIS FOAM TO THIS ADDRESS. MAILING YOUR APIUCATION TO THIS ADDRESS Wl..l SIGNl=KANTL Y DELAY PROCBSlNG.

INSTRUCTIONS FOR COMPLETING THE EFT AUTHORIZATION AGREEMENT

Al EFT roquom...., subject to• 15-day pre<enifiation l*1od Ill wt>leh all xcounu >re Wfifl9d by the Qual'1y1>9 f!Noo.I ~nsbM:iOn bvfore ""I Medic.are direct deposits MR ma~.

PART ~ REASON FOR SUBMISSION lndb,. your re.non for~ this form by <hecklng the _e>prb,. bolt How EFT -ollmonl. ~to your EFT - >«OUnt ilfonr.ation, CK G>nCl'llatlon of your [fl-~ II roo> >r• outhanl1>9 [fl - to lhe home omto of• m.il org>niz;;ltion of which roo>...., •member, roo>"'""' •tudl • - -mng the con11Xtor to moke ~due the prov;dor of senice to the XCOUlll moinulnod by U. - Offtte Of the clWn ~Tho - must be iigrlOd by .,, .MhorizRd official of the prowidr!r of - and an OU111o1'1?9d offlcl>I of the clWn ,,.,,... offic».

PART I: ACCOUNT HOlDER INFORMATION Ur-. I Ent« the pnMdor'WJppla's.'indDa payment pr0<Gn (11'1') bolet's lf!µI - ,,.,,,. Ot the,,.,,,. of the

~CK indMdual practitiomr, as repotmd lO the lntefNl-.... s.mc. (lltS) Tho XU>l.Wlt to which EFT -ts mado must eJOilsiwly be>r the.....,. Of the~ Ot _.., PDCU-. Ot the~ t>usirlosl ....... of the po<son CK mtity--wfth Mediate NOTI; ~billets !Ill& n>pon the '"9aJ bc.lslNs ....no proom.d on thelAS CP·57S 1onn.

Ur-. 2: £mRr the <Nin O<g.1ni2ation's name"' the...,,,,. otflce 1t9>1-n.>me if ct.lleront from the d\M1 ~tion name. NOTI; ~ers/IPP billen must repon the ~I t>UllMS,,,..,,,. "'°"-on the IRS CP-S7S lonn.

Lino .i: En tor the occount holder's pnaice loatlon strHt >ddross l.lno • Entor the occount hold«'s practice loc•tion city, sui., and zip code 1.1no S· Entor the tax ldentifiation number as rej)Orted to th<! IRS If tho busirM>U Is• CotpOt.tlOO, prov~ the Fodor'1I

employer identiootion number, otllerwlse prollide your SOCl•I Security Number If luutd, ontor the Medkllro ldQntification number as.signed by a Medicare feo-for.servlc:t contractor tt you ara not tnrollQd In MO<lkart. leavt! this fteld bl•nk.

Lint 6: IPP billers. enter tile HPID or OEID •ssigned by CMS. LIM 7: Entor th• 10 digit NPI number(s). Too NPI Is required to process this form.

NOTE; Institutional providers enter only ONE: NPI.

PART Ill: FINANCIAL INSTITUTION INFORMATION Lino 8: Entor your Financial Institution's nam• (tllls Is the n•mo of tho b•nk or qu•lllylng doposltory th•t wlll rocolve the

funds). Noto: Th• account name to which £FT paymonu will bo p•ld 11 to tho nomo submitted on P•rt II of tllis form. line t: Enter the financial institution's street addre-ss. Lint 10: Enter the financial institution's city or town. state or province. and zl:plposul code. line 11: EntQr the bank or financial institutional telephone number and cornxt ponon's name l.lno t2· Enter tile banlt or financial institutional nin&-dlgit routlng number, lndudlng oppl\Qblo loodlng zoros. l.lno U . Entor the provider'slsuppti«'sllPP ontity's occount number with the flnancl>l lnstltutlofl, lneludong ~· looding

Z«os. Selli!Ct the .XCount type.

II you do - submit this inlonn• tion. your EFT authorilltion -nt wtll bo .. wmec1 wttl1out IUrtlw prom.Ing.

PART IV: CONTACT PERSON l.lno 1• Em.. the n;imo Mid tide of • oontact pmon who an - quosuons >bout the lnformatlon llUb<nrtUcl on this

~588form.

l.lno IS Enw lhe contoct penon's telophone ..- rm. the <Onuct -··-· -

PART V: AUTIIOlllZATIOH U.. 1' By your signoture on this form - ore c«tifYing NI the actol#n ts dDwn in the - Of the PllrMCion « .,_

~.CK the~ Business Name of !he penon CK ..,till' Tho penon « onoty hos sole control Of the occount to which EFT dellosits are mado in acconl.1nc@with ;at opplbblt - l'OglUbOnS ond lnltN<tJOr4. Al .. , • .,.. ...... - the FlllOlldal Institution and the gjd penon CK lnl>ty.,. In xconlaKe wltl1 •I~~ rogulotJom .oo instructions with the effoctiw ma of the EFT >uthollutlon You must notJ1y CMS ~ "" clla>gl!S in the ocrount in sufficient lime to - the COtl1nCUlr...., the fin.ln<lol lnsbtuUon to oct on the dla>ges.

Tho EFT ...UOOOZ.tion form must be signed and d.1md by the...,. AIMO<Uod lto!l<Ment>tM °' • O.~ OfTid .. owmoc1 on the ~5 Medbre _, applic.nion- the - contr.ICtof Ila on ftlo Include•~ number wher• the Alnlloriled Reprosoncnive CK Dolegoted OffidaJ an be conuao<I

~ tins form Wltl1 the original signature in bl.a CK lob! onlt (no faalmolo llgn.>tw• an be xmpted) to the MtdlQro contrxtor tllat senricos your googr.iplliGll ....... Aro £FT >utllCKIUt.IOn form mun bo submitted f« ~ ModiUn Q)fltrxtof to wllOm you submit claims foe MediG>re paymonL To loc•te the mailing >ddrou f0< roo>r r ... f«-• conttoct«. go to: WWW can,goyfMedbreProvH»rSupEnroll.

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N atio nal S upplier C l earin gho u se MEDI CARE DivIEP OS SUPP LIER PARTICIPATION AGREEMENT - CMS 460

Medic a ·re Participa tion

To s i gn a part.icipat:io n ag r eement is to agree to accept assignment for a ll cover ed serv ices that you

proYide to M ed i ca r e pati ents .

A supplier"s participation status i s referring to whether they wish to ..accept .assignment: on claims or not.

Although there at'e some items on which assignment is mandatory regardless of the suppl ier's

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participation status. It i s not _,. in an y w a y_,. r eferrin g t o whether the suppl ier .,.,.ish e s to participate in the + Medicare program. Y ou may still bill Medicare if- yo u d o not choose to sign a participation agreement.

New s up p liers_,. who h a v e n ot: p r e viou s ly submitted a participation agr eement_,. h a v e up t o 90 days after

the date its number i s assigned to choose t o participate. If .a suppl ie r does nothing .. it w ill be li s t ed as

non-participating. If the suppl ier wishes to become a participat ing s u pplier, t he n it i s important: to

complete the participa tjng agreement form ( CMS 460 ( P D F _,. 217 KB)) and send it to t he NSC wit h in the

a l lotte d 90 days.

A new s up p lier w ho in itial ly submitted a n app licatio n to become participating cannot chang e t o non­

participating wit h in the first 90 days. The supplier has t ·o wait unt il the e nd of t h e year and submit a

letter during the open e nrollment period. T his letter must be r eceived before December 31 i n o r der to

become nonparticip a ting on Jan ua ry 1 of n e xt y ear.

N ote: It i s important t o note participatio n status i s associated wit h ..an e ntity (tax ID number) and not

a location . A b u siness e ntity with multipl e locations under t h e same ta x ID numbe r cannot c hoose to

have different participation statu ses for each location. All location s wil l a u tomatical ly be assig n ed the

s a me status ( participatin g or non-participating) dep endin g what the e n t it y h as chosen.

Prior to the open e nrollme n t period_,. which i s u sually be·tween mid-NoYember and t h e end of

December~ the N SC w ill send a letter a nd a participating ..agreemen t to each acti ._.e s upp lier on file. One

letter and ag r eement will be sent per ta x ID number to the mailing add ress on the s u pplier file.

Below i s additionaf inf o r mation about participatin g and what s up p liers n eed to d o if c h angin g the ir

s tatus during open e nrollme n t .

Why Pa.-t:icipa'be

Regardl e ss of the M edicare Part B services for wh ich you ..are billing .. participants h aYe 'one stop' billin g

for beneflci aries who h ave non-employment-related M edigap co...,e r age and who ass ig n b oth thei r

Medicare and Med igap payments to participants. After we h ave made payment.- we automatically send

the cl a im on to the rY1ediga p insurer for payment of- a ll coinsuran ce and ded u ctibl e amounts due unde r

the Cv1edigap policy . The (v1ediga p insurer must pay the participan t d irectly.

Wha-t:to Do

If you choose to be a participa nt::

If you aYe not cu rrently a participating Medica r e Durable Med ical Equipme n t _,. Prosthetics_,. Orthotics_,.

Suppl ies (DMEPOS) supplier.- complete the b lank agreemen t a n d mail it w ith a n origina l s ig n ature

o f an authorized official to t h e National Supplie r C learinghou se. On the form.- show the n ame(s)

and identification number( s ) und e r w h ich you b il l. T hi s agreement must be submitted only durin g

the open enrol lment p e riod. This open enro llment period is between mid-November and the end

o f Dece r-n ber.

If you w is h to change to non-participatin g .. you must submit a lett.e r- signed by the a u t h orized

official to t h e NSC durin g the o pen e n roll m ent pe r iod. The chan ge will be effectj v e Janu a ry 1 of

the follow ing year.

If you dec ide not: to participate:

Do not hing if you do not have a participatin g agr eement in effect at a ny location

I f you wish to chang e to no n -participatin g .. you must submit a lett.et' signed by the a u t h orized

official to the NS C during t h e o pen e n rollment period . The c h a n ge will b e effecti v e January 1 of

the fo llow ing year.

W e hope yo u will decide to be a M edi ca r e participant.

Please call 866-238-9652 if you ha!.J'e an y question s or need further information o n DMEPOS

participation.

DEPARTMENT OF HEALTH AND HUMAN SEltVICES CENTERS FOR MEDtCA.RE & M:EDtCAID SERVICES

FORM APPROVED OMB NO. 0938-0373

MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT

Name(s} and Address of Part:icipan-t• National Provider Identifier (N.PO•

•un all names and the NPI under which the partic.ipant files daims wi'th 'the Medicare Admlnistra'tive: Contractor (MAC)lcarrier with whom this ag,.eeme.nt. is being filed_

The above named person or organization,, called "·the participant_"~ hereby enters into an agr.eement '\.vi th the Medicare program to accept assigmnent of the Medic.are Part B payment for all services for which the panicipant is eligible to accept assignxnent under the Medicare law and reguJations and which are furnished v.rhile this agreement is in effect..

1. !\leaning o f Assignment: For purposes of this agreement, accepting ass ignment of the Medicare Part B payment means requesting direct Pan B paymenl from the Medicare program. Under an assignn1ent~ the approved charge. detennlned by tbe MAC/carrier. shaU be che fuU charge for tbe service cmtered under Part B. The participant shall nor collect from the beneficiary or other person or organization for covered services more than the applk'1hle deductible and coinsurance.

2. E ffective Date: If the participant files the "eoreement with auy MAC/carrier during tbe enrollment period. the agreement becomes effective ------------

3. Term and Termination oC Agreement This agre>e,ment shall continue in effect through December 3 I following lhe date the agreement becomes effective aud shall be renewed automatically for each 12-month period January l through December 31 thereafter unless one of the following occurs:

a. During the enrollment period prov ided near the end of auy calendar year. the participant notifies ia v.rriting every _MAC/carrier with '\vhom the participant has filed the agreeme:rn or a c.opy of the agreement that the participant wishes to terminate the agreement at the end of the current tenn. In the event such notification is mailed or delivered during the enrollment period provided near the end of any calendar year. the agreement shall end on December 31 of that year.

b. The Centers for ~Iedicare & Medicaid Services may find. after notice to and opportunity for a bearing for the participanL tbat the participant has substantially f"J.iled to comply with lhe 3:,<>reemeoL In the event such a finding is made. the Centers for ~edic.are & Medicaid Services will notify the panicipant in writing that the agreement "vill be tenninated at a time designated in tbe notice. Civil and criminal penalties may also be imposed for violation of the agreement.

Signature of participant: (or authorized r-epresental:ive of participating o.rganizalion) OaU!

Tide {if signer- is a\l'thorized represeo"tative of organization) Office Phone Number (indudl~ area code)

Received by (name o-f canie<) I tn;tials of Carrie< Officia I Effective Da~e

According -i-o t:he P'aperworlt Reduction Act of 1995. no persons are required to resporxf to a collection of information unless it displays a valid OMB control number-. The valid OMB control num.bef- for this information collection is 0938-0373_ The tim.e requited to complete dii:s information collection is estima't.ed to average 1 S minutes per response, inctuding the time -.:o review- i:nstn.J:Ctions. search existing da'ta resources,, gather t:h.e dat.a needed and com.pfete and review ttle information collection. If you ha"Ye any comments concerning the accuracy of the time est.ilnal:.e(s) or suggestions fot improving t:his form. please write to: CMS~ 7500 Seo.Jetty Boulevard .. Attn:: PRA Reports Oearance_ Offk.er. Battimcwe~ Ma:rytand 21244-1850.

Form CMS-460 (Cl4f10)

NATIONAL SUPPLIBR CL£ARINGHOUSE •

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Pa lmetto GB A Med icare

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I Ad ditio nal Inform atio n I Orthotics & Prosthetics . ..

National Supplier Clearinghouse ORTHOTICS & PROSTHETICS SUPPLIERS

All s upp lie rs are re quired to b e in com pliance with the Medicare DMEPO S s u pplier stand ards . As a

supplier of O rthotics and/or P rosthe tics (O&P}, keep the fo llowing in m ind a s you ope rate '/OUr

bu siness.

Suppfiet"' Stand.ant # 1 st ate s a supplier 'o perates its b usiness and fumis hes Medicare-covered it e ms in

com pliance with all applicable Fed era l a nd State lice nsure and re gulatory requirements.' If your stat e

require s a n O&P license o r certification fo r these types of s pecialties a nd p roducts/services> t hen a

cop y o f t his licen se m ust be inclu ded with th e CMS 8SSS application fo rm.

Suppfiet"' Stand.ant # 4 st ate s a supplier 'fills o rders, fabric.ates > o r fi ts ite ms from its o wn inventory, o r

by contracting with other co m pan ies fo r th e purchase o f items ne cessa ry t o fi ll t he o rder. I f it does .. it

m ust p ro vide, upon req uest... cop ies of contracts or o ther docume ntation s h owing co mpliance with t h is

sta ndard. ' The Centers fo r Medicare a nd Me d icaid Services (CMS) interprets 1834 (j) ( 1 ) of t he S ocial

Serurit'I Act t o m ean the supplier m ust be t he one furnis h ing the s ervices/it e ms, a n d m ust be the one

billing fo r t h e s ervices/item s . Specifically> a supplier m ay n ot contract with o ther companie s fo r

service s .

Supplier Standard # 12 states a s upplie r 'is respons ible for delive ry a n d must instruct b en eficiaries o n

use of Med ic.are covere d item s and m aintain p roof of d e livery.'

Pursuant t o Title 42 of the Code o f Federal Reg ulations, S ecs. 405. 8 74 a nd 424.57, your CMS S SSS

app lication fo rm will be d enied if yo u are not in com pliance with these standa rds a s a supplier of O&P.

These d enials h ave t he concurrence o f CMS.

If you h ave any q uestions, yo u m ay call the HSC t oll free at 866-238-9652.

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How Do The Supplier Standards Effect My Daily Operations?

•  Operating As a Store •  Inspection by CMS •  Signage Listing Hours Of Operations •  Have Landline Phone •  Provide Written Instructions •  Provide Warranty Materials •  Vendor Contracts for Supplies

Facility Inspections

•  Usually Brief & Conducted SACU •  Looking for Physical Presence •  Allowed During Hours of Operation Listed On

855S •  Some Inventory •  Signage & Supplier Standards •  If Asked You Must Be Able to Prove Compliance

with Supplier Standards

8.” A supplier must permit CMS, or its agents to conduct on-site inspections to ascertain the supplier’s compliance with these standards. The supplier location must be accessible to beneficiaries during reasonable business hours, and must maintain a visible sign and posted hours of operation.”

Rules on Signage

•  At First Entrance to Office •  “Permanent” Can’t Be Simple or Easily Removed •  Signage Access By Owner or Employee Only •  Cannot Be “By Appointment Only”

Warranty

•  Each Product Requires a Warranty •  No Mandatory Warranty Period •  Range from None to Lifetime •  Provide Written Warranty Statement to Patients

Supplier Standard # 6: “A supplier must notify beneficiaries of warranty coverage and honor all warranties under applicable State law, and repair or replace free of charge Medicare covered items that are under warranty”.

Patient Instructions and Delivery Supplier Standard #12

“A supplier is responsible for delivery and must instruct

beneficiaries on use of Medicare covered items, and maintain proof of delivery”.

Patient Instructions •  Product Specific •  Easy Vocabulary •  Illustrations •  Be specific About Problem Notification •  Instructions May Be Provided to You By Mfg •  Instructions May Be Written By You or Office Staff

Therapeutic Shoe/Insert Instructions

•  “Wear Your Shoes Only One Hour More Each Day for the First Two Weeks, Preferably Inside Your Home

•  Any redness or signs of irritation necessitate stopping use of the shoes and inserts.

•  Report this to the doctor’s office immediately”

Instructions- Your Records

The patient signed a receipt of delivery and was given a copy. The patient also received written warrantee and usage information. The patient was specifically instructed on how to apply (“Don”) and remove the device. They were told the device must be inspected daily prior to its application and then upon its removal in order to evaluate for any defects. The patient understands if they have any questions concerning the integrity and safety of the device they are to refrain from usage until I have inspected the device.

Complaint Log and Resolution

19. A supplier must have a complaint resolution protocol established to address beneficiary complaints that relate to these standards. A record of these complaints must be maintained at the physical facility.

20. Complaint records must include: the name, address,

telephone number and health insurance claim number of the beneficiary, a summary of the complaint, and any actions taken to resolve it.

Protocol for Resolving Complaints from Medicare Beneficiaries

•  The patient has the right to freely voice grievances and recommend changes in care or services without fear or reprisal or unreasonable interruption of services. Services, equipment and billing complaints will be communicated to the office manager and/or Doctor _______. These complaints will be documented in the Medicare Beneficiaries Complaint log, and the completed forms will include the patients name, address, telephone number, and health insurance claim number, a summary of their complaint, the date it was received, the name of the person receiving the complaint, and a summary of actions taken to resolve the complaint. 

•  All complaints will be handled courteously and professionally. All logged complaints will be investigated, acted upon, and responded to in writing or by telephone, by the office billing manager within a reasonable time after the receipt of the complaint. If there is no satisfactory resolution of the complaint, the doctor will be notified. The patient is to be notified of this protocol at the time services are first initiated.

Your Letter Head

Medicare Beneficiary Complaint Log

Date of receipt of Complaint: ________________________________________ Patients Name: __________________________________________________ Patients Address: ___________________State__________ Zip Code________ Patients Telephone Number: ________________________________________ Patients Medicare or Health Insurance Number: _________________________ Description of Complaint: __________________________________________ ______________________________________________________________ _______________________________________________________________ Action taken to resolve the complaint: _________________________________ _______________________________________________________________ _______________________________________________________________ _________________________________ _______ Signature of employee taking complaint Date _______________________________ _______ Patients Name Date

For Medical-Legal Purposes

•  “Prior to the patient leaving the office the device was inspected and is in good working order free of any visible defects.”

•  “Use of this CAM Walker in any manner other

than previously discussed with Dr. Smith or his staff and/or included in the above instructions will void the warranty and may result in severe injury.”

Follow Up DME Related Visit

•  The patient’s custom fabricated AFO was examined. The device appears to fit well and is free of any visible defects.

•  The patient’s custom AFO was examined and a screw on the medial

ankle hinge was noted to be loose. The hole in the AFO shell was noted to be sufficient and there was no defect in the shell. The screw and nut were replaced and tightened appropriately with “locktite” applied to the bolt. The patient was advised that if there is any shifting of the bolt or apparent loosening to discontinue the use of the device and have a family member bring the device to the office.

•  The patient’s AFO was examined and a large hole was present in the

shell of the AFO where the rivet should go through the Lateral Malleolar portion of the hinge. This will need repair by the manufacturer and the device was removed from the patient’s service. He was provided with a pre-fabricated device to use for the time being and was advised to severely curtail his ADL’s…….. Patient will be notified when repairs are completed.

Follow Up DME Related Visits •  The Compression stockings (or diabetic socks)

have numerous tears and runs. These devices should be removed from service.

•  The therapeutic shoes & inserts are worn and

irreparably damaged and require replacement & should be removed from service.

•  The shoes have significant varus wear pattern on the heels causing the patient to be in severe genu varum and unstable.

•  The patient was informed to either get rid of the shoes or have them repaired prior to wearing them again.

Compliance Methods •  Prepare Proper Paperwork (NSC Guidelines) •  Obtain a Thorough Patient History •  Order From Well Known High Quality

Manufacturers •  Dispense Legible Written Instructions •  Speak With The Referring Doctor •  Maintain Copies of Prescriptions •  Inspect Devices Regularly •  Adhere to Manufacturers Guidelines •  Receive & Log Proper Training of all Staff •  Be Modest and Be Realistic With Expectations •  Remove Damaged Products & Log Your Repairs •  Use Your Digital Camera

•  Review the beneficiary’s record as appropriate and incorporate any pertinent information, related to the beneficiary’s condition(s) which affect the provision of the DMEPOS

•  Instructions: Clear written or Photos •  Beneficiary and/or Caregiver Training •  Model & Serial Numbers of Non Custom DME •  Investigate Any Adverse Effects •  Ensure DME Can Be Used Safely

DMEPOS Quality Standards October 2008

DMEPOS Quality Standards

•  Provision of custom fabricated or custom fitted devices (i.e., other than off-the-shelf items) requires access to a facility with the equipment necessary to fulfill the supplier’s responsibility to provide follow-up treatment, including modification, adjustment, maintenance and repair of the item(s).

•  Individuals supplying the item(s) set out in this appendix must possess specialized education, training, and experience in fitting, and certification and/or licensing.

DMEPOS Quality Standards October 2008

•  12. Therapeutic Shoes and Inserts: Includes depth or custom-molded shoes along with inserts for

individuals with diabetes (Refer to Section 140 of Chapter 15 of the Medicare Benefit Policy Manual) •  a. Custom-Molded Shoes: •  Are constructed over a positive model of the patient’s foot; •  Are made from leather or other suitable material of equal quality; •  Have removable inserts that can be altered or replaced as the patient’s condition warrants; and •  Have some form of shoe closure. •  b. Depth Shoes: •  Have a full length, heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of

additional depth used to accommodate custom-molded or customized inserts; •  Are made from leather or other suitable material of equal quality; •  Have some form of shoe closure; and •  Are available in full and half sizes with a minimum of three widths so that the sole is graded to the

size and width of the upper portions of the shoes according to the American standard last sizing schedule or its equivalent. (The American standard last sizing schedule is the numerical shoe sizing system used for shoes sold in the United States.)

•  c. Inserts: •  Are total contact, multiple density, removable inlays that are directly molded to the patient’s foot or a

model of the patient’s foot and that are made of a suitable material with regard to the patient’s condition.

DMEPOS Quality Standards October 2008 A. Intake & Assessment

Supplier Product-Specific Service Requirements, the supplier shall: • Assess the beneficiary’s need for and use of the orthoses/prostheses (e.g., comprehensive history, pertinent medical history (including allergies to materials), skin condition, diagnosis, previous use of an orthoses/prostheses, results of diagnostic evaluations, beneficiary expectations, pre-treatment photographic documentation (when appropriate); • Determine the appropriate orthoses/prostheses and specifications based on beneficiary need for use of the orthoses/prostheses to ensure optimum therapeutic benefits and appropriate strength, durability, and function as required for the beneficiary; • Formulate a treatment plan that is consistent with the prescribing physician’s dispensing order and/or the written plan of care, in accordance with Medicare rules, and consult the physician when appropriate; • Perform an in person diagnosis-specific functional clinical examination as related to the beneficiary’s use and need of the orthoses/prostheses (e.g., sensory function, range of motion, joint stability, skin condition (integrity, color, and temperature), presence of edema and/or wounds, vascularity, pain, manual muscle testing, compliance, cognitive ability and medical history); • Establish goals and expected outcomes of the beneficiary’s use of the orthoses/prostheses (e.g., reduce pain, increase comfort, enhance function and independence, provide joint stability, prevent deformity, increase range of motion, address cosmetic issues and/or promote healing) with feedback from the beneficiary and/or prescribing physician as necessary to determine the appropriateness of the orthoses/prostheses; • Communicate to the beneficiary and/or caregiver(s), and prescribing physician the recommended treatment plan, including disclosure of potential risk, benefits, precautions, the procedures for repairing, replacing, and/or adjusting the device or item(s), and the estimated time involved in the process; • Assess the orthoses/prostheses for structural safety and ensure that manufacturer guidelines are followed prior to face-to-face fitting/delivery (e.g., beneficiary weight limits, ensuring that closures work properly and do not demonstrate defects); and • Ensure the treatment plan is consistent with the prescribing physician’s dispensing order.

DMEPOS Quality Standards October 2008

C. Training/Instruction to Beneficiary and/or Caregiver(s) The supplier shall: • Provide instructions to the beneficiary and/or caregiver(s) for the specific orthoses, prostheses, or therapeutic shoe/inserts as follows:

• How to use, maintain, and clean the orthoses/prostheses (e.g., wearing schedules, therapy, residual limb hygiene, other pertinent instructions);

• How to don and doff the orthoses/prostheses, including how to adjust closures for proper fit;

• How to inspect the skin for pressure areas, redness, irritation, skin breakdown, pain, or edema;

•  How to utilize an appropriate interface (e.g., stockinettes, socks, gloves, shoes) to accommodate the orthoses/prostheses where appropriate;

•  How to report any problems related to the orthoses/prostheses to the supplier or the prescribing physician if changes are noted (e.g., changes in skin condition, heightened pain, increase in edema, wound concerns, changes in general health, height, weight, or intolerance to wearing the orthoses/prostheses as applicable);

• How to schedule follow-up appointments as necessary; and schedule for tolerance of the orthoses/prosthesis;

• Establish an appropriate “wear schedule”

• Provide necessary supplies (e.g., adhesives, solvents, lubricants) to attach, maintain, and clean the items, as applicable, and information about how to subsequently obtain necessary supplies; and

•  Refer the beneficiary back to the prescribing physician as necessary for intervention beyond the supplier’s scope of practice

DMEPOS Quality Standards October 2008

The supplier shall: •  Have access to a facility with the equipment necessary to provide follow-up treatment and fabrication/modification of the specific O&P Product • Review recommended maintenance with the beneficiary and/or caregiver(s); • Solicit feedback from the beneficiary and/or caregiver and prescribing physician prn. to determine the effectiveness of the orthoses/prostheses (e.g., wear) • Review and make changes to the treatment plan based on the beneficiary’s current medical condition; • Continue to assist the beneficiary until the O&P Product reaches the optimal level • Provide appropriate follow up treatment consistent with what has been dispensed and the specific care rendered; • Make appropriate recommendations

FAQ

Doctor (Supplier) Required to be Onsite During Inspection?

Supplier Standard #8: “The supplier location must be accessible to beneficiaries

during reasonable business hours, and must maintain a visible sign and posted hours of operation.”

Supplier Standard #13

“ A supplier must answer questions and respond to complaints of beneficiaries, and maintain documentation of

such contacts.”

A trusted employee should always be in the office who has the knowledge required to pass the inspection

What Should Be Easily Accessible for Inspection?

•  Signage •  Supplier Standards •  Inventory •  Delivery, Complaint Resolution & Warranty

Forms •  Complaint Log Book •  Insurance Certificate •  Vendor Contract

Can I Make an Appointment for an Inspection?

•  No Appointments •  Randomly Made By SACU •  Accessibility During Hours Listed on 855S •  2 Missed Inspections = Revocation of DMEPOS for 2 Years

What’s a Vendor Contract?

A vendor contract is as simple as a credit application with a vendor. It stipulates your credit amount/month and the average time it will take to fill an order.

Why Do I Need Vendor Contracts? Supplier Standard 4

“A supplier must fill orders from its own inventory, or must contract with other companies for the purchase of items necessary to fill the order. A supplier may not contract with any entity that is currently excluded from the Medicare program, any State health care programs, or from any other Federal procurement or non-procurement programs.”

WHAT IS CONSIDERED PERMANENT VISIBLE SIGNAGE IN REGARD TO SUPPLIER STANDARD 7? A. The supplier should maintain a permanent visible sign(s) in plain view and should post hours of operation. The sign must be visible to the public and posted outside of the facility. If the supplier's place of business is located within a building complex, the sign(s) must be visible at the main entrance and/or lobby area of the building and show the exact location of the supplier within the building. However the hours can be posted at the entrance of the supplier with a separate sign. Permanent Signage including the hours of operation should not be easily removed or detached by weather or a person who does not have a business need to remove it. Taped paper signs are not acceptable. Beneficiaries should be able to locate the supplier and their hours of operation through the use of these permanent signs without help from the supplier or other parties

DO I HAVE TO SUBMIT AN AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER (CMS 588) TO THE NSC? Answer: DMEPOS suppliers are required to submit the EFT agreement with the application form when initially enrolling or submitting an application for a new location. When completing the form, suppliers should ensure the form has the original signature of the authorized or delegated official. Further, suppliers must include with each form submitted a voided check, preprinted deposit slip or confirmation of account information on bank letterhead for verification of the account number. The NSC will then send the agreement to the appropriate DME MAC for processing. The CMS 588 (PDF, 112 KB) form may be downloaded from the CMS website.

Do I Need to File an Application for Each Office Location?

•  You Must Have a Provider Transaction Number (PTAN) from Each Physical Location from Which You Regularly Transact Business

•  Failure to Do So Can Result in Revocation or Suspension of Your DMEPOS Privileges for One Year

Supplier Standard #24

All supplier locations, whether owned or subcontracted, must meet the DMEPOS quality standards and be separately accredited in order to bill Medicare

Can I Participate in One Office and Not Another?

Only if the Tax ID Numbers are Different

Do All Thirty Supplier Standards Apply to Me? •  Only Those Which Apply to Those Products and Type of

Supplier Apply

•  Example: Those Which Apply Only to Oxygen Suppliers Do Not Apply to You

•  Exemptions: Requirements for Facility Accreditation, Surety Bonding,30 Hour of Operation

What Do I Do About Vacations, Holidays?

Post Signage of Expected Date Of Closure and Return Try and Have Office Always Staffed During Revalidation Period