RO Countersigning Provider Agreement

2781 - RO Countersigning Provider Agreement (Rev. 1, 05-21-04) After determining that all title XVIII and appropriate civil rights requirements are met, the RO signs the Health Insurance Benefits Agreement (Form CMS-1561). Before countersigning the provider agreement the RO must be certain that the name on line 2 of the agreement after the term “Social Security Act” does, in fact, include both the true name of the provider entrepreneur and the trade name of the entity, rather than only the trade name. For example, a partnership of several persons doing business as East Care Home Health Services completes the second line of the agreement to read: “Robert Johnson, Louis Miller, and Paul Allen, ptrs., East Care Home Health Services;” the ABC Corporation, using the trade name Community General Hospital, completes the agreement to read: “ABC Corporation d/b/a Community General Hospital.” In the case of sole proprietorship, the agreement will read: “John Smith d/b/a Mercy Hospital.” The business name on the agreement should ordinarily conform to the name on all official (i.e., IRS) correspondence/forms concerning payroll withholding taxes, such as the SS-4, W-3, S-l, or 941 forms. The instructions on the SS-4 (Application for Employer Identification Number) clearly differentiate between the true or entrepreneurial name and the trade name. If a question arises regarding an owner’s name as it appears on the provider agreement, the RO should refer to the above documents.