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


Answer:
Supplier standard 3 states '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. Examples of individuals able to sign include: 

  • 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

Only the authorized official has the authority to sign the initial enrollment application and/or assign delegated official(s). The authorized official(s) will sign the certification statement in the section for authorized official signature(s) and the delegated official(s) will sign the certification statement under the section assignment of delegated official(s) (along with the authorized official’s signature.) Once the authorized and/or delegated official(s) are added to the enrollment record, they are the only individuals who will be able to sign to add an additional location, make any changes to the enrollment, submit a reactivation or to revalidate. 

The certification statement must have the 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.


Last Updated: 03/20/2025