(Certification Statement) - Form CMS-855I

10.3.1.3.6 - Section 15 (Certification Statement) - Form CMS-855I (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. Applicability and Format Unless otherwise specified, the instructions in this section 10.3.1.3.6 apply to (1) signatures on the paper Form CMS-855I and (2) electronic signatures. For paper applications, valid signatures include handwritten (wet) signatures in ink and digital/electronic signatures (digital or electronic signatures such as those created by digital signature options established via software, such as Adobe). For web applications, electronic signatures are required; the contractor can contact its PEOG BFL for questions regarding electronic signatures. B. Signatories The enrolling or enrolled physician or non-physician practitioner is the only person who can sign the Form CMS-855I. (This applies to initial enrollments, changes of information, reactivations, revalidations, etc.). This includes solely-owned entities listed in the Business Information section of Section 4 of the Form CMS-855I. A physician or non-physician practitioner may not delegate the authority to sign the Form CMS-855I on the physician’s/practitioner’s behalf to any other person. (In the case of death, however, an executor of the estate may sign on behalf of the deceased supplier, though this only applies to change of information applications.) C. Paper Submissions A signed certification statement must accompany the paper Form CMS-855I application. If the supplier submits an invalid certification statement or fails to submit a certification statement at all, the contractor shall still proceed with processing the application. An appropriate certification statement shall be solicited as part of the development process – preferably via the PCV, e-mail, or fax. This includes certification statements that are: (a) unsigned; (b) undated; (c) signed (as reflected by the date of signature) more than 120 days prior to the date on which the contractor received the application; (d) signed by someone other than the physician or non-physician practitioner (except as noted in section 10.3.1.3.6(B)); (e) missing; or (f) stamped. The contractor shall send one development request to include a list of all of the missing required data/documentation, including the certification statement. The contractor may reject the supplier’s application if the supplier fails to furnish the missing information on the enrollment application - including all necessary documentation - within 30 calendar days from the date the contractor requested it. Unless stated otherwise in this chapter or in another CMS directive: (i) The contractor shall begin processing the application upon receipt and shall develop for missing certification statements and all other missing information. (ii) The certification statement may be returned via scanned email or fax. (iii) Signature dates cannot be more than 120 days prior to the receipt date of the application. (iv) The contractor need not compare the supplier’s signature with one already on file for that person to ensure it is the same individual. (v) The contractor shall not request the submission of a driver’s license or passport to verify a person’s signature or identity. D. PECOS Submissions If the supplier submits an invalid certification statement, the contractor shall treat this as missing information and develop for a correct certification statement – preferably via the PCV, e-mail or fax. (This includes certification statements that are: signed by someone other than the physician or non-physician practitioner (except as noted in section 10.3.1.3.6(B)). The contractor shall send one development request to include a list of all of the data/documentation to be furnished or clarified, including, as applicable, the certification statement. The contractor may reject the supplier’s application if the supplier fails to furnish said data/documentation within 30 calendar days from the date the contractor requested the missing information or documentation. Unless stated otherwise in this chapter or in another CMS directive: (i) The contractor shall (a) begin processing the application upon receipt via PECOS, (b) perform all required manual validations, and (c) develop for any needed clarifying or missing information or documentation consistent with section 10.3 above and all other applicable instructions in this chapter. (ii) The contractor need not compare the supplier’s signature with one already on file for that person to ensure it is the same individual. (iii) The contractor shall not request the submission of a driver’s license or passport to verify a person’s signature or identity. E. Certification Statement Development The supplier must submit a newly signed certification statement as part of a development request as follows: (i) Paper applications: Via scanned e-mail, fax, or mail. (Only the actual signature page is required; the additional page containing the certification terms need not be submitted. This also applies to the supplier’s initial submission of a certification statement; such instances require the submission of only the signature page and not the certification terms.) (ii) Web applications – Via electronic signature. F. Privacy Statement All information collected on the Form CMS-855I shall be entered into PECOS. The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used for a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure of data is known as a “routine use.” CMS will only release PECOS information that can be associated with an individual as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both identifiable and non- identifiable data may be disclosed under a routine use. CMS will only collect the minimum personal data necessary to achieve the purpose of PECOS. To view the routine uses in their entirety, go to: https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and- Systems/Privacy/Downloads/0532-PECOS.pdf.