6, 8, 12, 13, and 14 - Form CMS-855I

10.3.1.3.5 - Sections 6, 8, 12, 13, and 14 - Form CMS-855I (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) (Except as otherwise stated, the PECOS policies in section 10.3 supersede those in sections 10.6.7 et seq., 10.6.8, and 10.6.9 (e.g., communicating with the provider via the PCV.) Section 6 - See section 10.6.7 et seq. of this chapter for information concerning managing individuals and organizations. Section 8 - See section 10.6.8 of this chapter for information concerning billing agencies. (Note that if the telephone number in this section is blank, the number can be verified with the supplier via telephone, the PCV, e-mail, or fax. If the entire section is blank (including the check box), no additional development is needed.) Section 12 – See the Supporting Documents section of the Form CMS-855I for information concerning supporting documents. Section 13 - Contact Persons • If this section is completely blank, the contractor need not develop for this information and can simply contact the physician/practitioner. • If the “Contact the individual listed in Section 2A” checkbox in Section 13 is checked but the contact person information is incomplete (e.g., no telephone number listed), the contractor can either: (1) develop for this information via telephone, the PCV, e-mail, or fax; or (2) contact the physician/practitioner. See section 10.6.9 of this chapter for more information concerning the Contact Persons section of the Form CMS-855I. Section 14 - Penalties for Falsifying Information See the Penalties for Falsifying Information section of the Form CMS-855I for an explanation of penalties for deliberately furnishing false information in this application to gain or maintain Medicare enrollment.