(Certification Statement) - Form CMS-855O

10.3.1.5.2 – Section 8 (Certification Statement) - Form CMS-855O (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. General Policies The enrolling or enrolled physician or other eligible professional is the only person who can sign the Form CMS-855O. This person cannot delegate the authority to sign the Form CMS-855O to any other individual. This applies to initial enrollments, changes of information, reactivations, voluntary withdrawals, etc. (Note: In the case of death, an executor of the estate may sign on behalf of the deceased supplier. This situation would only apply to change of information applications.) For paper applications, handwritten (wet) signatures in ink and digital/electronic signatures (digital or electronic signatures such as those created by digital signature options created in software, such as Adobe) are acceptable. For web applications, electronic signatures are required; the contractor may contact its PEOG BFL for questions regarding electronic signatures. B. Paper Applications A signed certification statement shall accompany the paper Form CMS-855O application. If the supplier submits an invalid certification statement or fails to submit any 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 practitioner (except as otherwise noted in this section 10.3.1.5.2); (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 the missing information or documentation. 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) For paper applications that require development, the supplier’s dated signature must be on the certification statement that is to be submitted within 30 days. (v) For paper changes of information applications---and except as stated in section 10.3.1.5.2(A)- -the contractor shall only accept a certification statement signed by the individual physician or practitioner. (vi) The contractor need not compare the Form CMS-855O signature with the same person’s signature on file to ensure it is the same individual. (vii) The contractor shall not request the submission of a driver’s license or passport to verify a person’s signature or identity. C. PECOS Submissions 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 and all other applicable instructions in this chapter. (ii) 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 practitioner who signed the form (except as otherwise noted in this section 10.3.1.5.2(A)). The contractor shall send one development request to include a list of all of 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 of the contractor’s request. (iii) For PECOS applications that require development, the supplier’s dated signature must be on the certification statement to be sent in within 30 days. (iv) For PECOS change of information applications, the contractor shall only accept a certification statement signed by the individual physician or practitioner. (v) The contractor need not compare the Form CMS-855O signature with the same person’s signature on file to ensure it is the same individual. (vi) The contractor shall not request the submission of a driver’s license or passport to verify a person’s signature or identity. D. Certification Statement Development Newly signed certification statements furnished per a development request must be submitted as follows: (i) Paper applications -- Via scanned email, fax, or mail. Only the actual signature page is required; the provider need not submit the additional page containing the certification terms. (This also applies to the provider’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. E. Privacy Statement 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.” The 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.