OMB control number: 09381313 Expiration Date: 052019MEDICAREWaiver Application for Providers and SuppliersSubject to an Enrollment MoratoriumCMS10629PROSPECTIVE PROVIDERS AND SUPPLIERS SHOULD COMPLETE.
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How to fill out the CMS CMS-10629 online
The CMS CMS-10629 form is essential for prospective providers and suppliers looking to enroll in Medicare services in areas with limited beneficiary access. This guide will assist you in filling out the form accurately and effectively, ensuring that you meet all necessary requirements for submission.
Follow the steps to successfully complete the CMS CMS-10629 form.
- Click 'Get Form' button to access the CMS CMS-10629 online application and open it in your preferred editor.
- Begin by carefully reading the instructions provided in Section 1, as it outlines the eligibility criteria and important details regarding the application process.
- Proceed to Section 2, where you will provide a detailed evaluation of access to care in your proposed service area. Describe any barriers that prevent beneficiaries from receiving care.
- In Section 3, fill out the general information about your provider/supplier details. Ensure to include your Medicare identification number, tax identification number, any existing national provider identifiers, and your specific provider type.
- Complete the contact information section. Provide the name and details of the contact person who will handle inquiries about the application.
- Define your proposed service area by listing the states, ZIP codes, and counties where you plan to provide services.
- If applicable, proceed to Section 4 to discuss fingerprinting requirements for individuals with a 5% or greater ownership interest in your entity. Schedule your fingerprinting with Accurate Biometrics.
- In Section 5, disclose any affiliations and unpaid federal debts as required. Ensure accuracy to avoid potential penalties.
- Review the penalties for falsifying information included in Section 6 to understand the consequences of providing incorrect information.
- In Section 7, include the certification statement by obtaining the authorized official's signature. This person will bind your organization to the application requirements.
- Finally, attach all mandatory supporting documents outlined in Section 8, including the access to care determination, documentation of any federal debts, fingerprint submissions, and the application fee.
- Once you have completed all sections and verified the information, submit the application by email to the designated provider enrollment waiver mailbox.
Complete your CMS CMS-10629 form online today to facilitate your Medicare enrollment process.
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