What individuals may sign the certification statement found in PECOS or section 15 of the CMS 855S?

Answer:
Supplier standard 3 states that 'an authorized individual (whose signature is binding) must sign the application for billing privileges.'

The CMS 855S application form is a legal contract with the government. Only an individual who can legally and financially bind the supplier to the laws, regulations and program instructions of the Medicare program can sign the certification statement. This individual must be one of the following:
  • General partner
  • Chairman of the board
  • Chief financial officer
  • Chief executive officer
  • President
  • Direct owner (with 5 percent or greater ownership)
Individuals unable to sign the certification statement are:
  • Independent contractors
  • Billing agency representatives
  • Individuals with no ownership, partnership or managing control (e.g., administrative assistants)
  • Individuals who cannot legally bind the entity

On the initial application submitted by an entity, the supplier is required to choose from the list above in order to assign authorized and/or delegated officials. On the initial application the authorized official(s) will sign section 15 and the delegated official(s) will sign section 14 (along with the authorized official's signature). Once the authorized and/or delegated official(s) are chosen, they are the only individuals who will be able to sign in order to change any information or add an additional location.

The certification statement must have the original signature of an individual that meets the definition of an authorized official before it can be processed or that of a delegated official when appropriate.

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National Supplier Clearinghouse

Palmetto GBA, AG-495

P.O. Box 100142

Columbia, SC 29202-3142

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