License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the AMA.

You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement.

Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. Applications are available at the AMA website.

This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements.

AMA Disclaimer of Warranties and Liabilities.

CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. No fee schedules, basic unit, relative values or related listings are included in CPT. The AMA does not directly or indirectly practice medicine or dispense medical services. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.

CMS Disclaimer

The scope of this license is determined by the AMA, the copyright holder. Any questions pertaining to the license or use of the CPT must be addressed to the AMA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

This license will terminate upon notice to you if you violate the terms of this license. The AMA is a third party beneficiary to this license.

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

End User License Agreement

THE LICENSE GRANTED HEREIN IS EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THIS AGREEMENT. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT.

IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN.

IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT-4 only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT-4 is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT-4 for resale and/or license, transferring copies of CDT-4 to any party not bound by this agreement, creating any modified or derivative work of CDT-4, or making any commercial use of CDT-4. License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association website.
Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Please click here to see all U.S. Government Rights Provisions.
ADA DISCLAIMER OF WARRANTIES AND LIABILITIES. CDT-4 is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. No fee schedules, basic unit, relative values or related listings are included in CDT-4. The ADA does not directly or indirectly practice medicine or dispense dental services. The sole responsibility for the software, including any CDT-4 and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. The ADA is a third-party beneficiary to this Agreement.
CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT-4 should be addressed to the ADA. End users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. If the foregoing terms and conditions are acceptable to you, please indicate your agreement by clicking below on the button labeled "I ACCEPT". If you do not agree to the terms and conditions, you may not access or use the software. Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen.

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Home Health & Hospice Provider Enrollment Interactive Help Tool

If you choose to complete paper forms to enroll in Medicare for the first time, or make changes to your existing enrollment information, use this tool to.

Help you complete the CMS Medicare enrollment application
Identify the supporting documentation required to complete the enrollment process
Receive a barcoded application coversheet that will help CGS process your application in a timely manner

Instructions: Answer the question(s) below. The tool will identify the appropriate form(s) to complete and the supporting documents required with the application submission

1. Are you currently enrolled as a Home Health Agency or Hospice provider with CGS Administrators, LLC?

Yes No

2. Are you adding a practice location?

Yes No

3. Have you paid the fee requirement as prescribed by CMS?

Yes No

4. Complete form CMS 855A as identified below:

This tool is for those Providers with an active PECOS enrollment wanting to add, change, or delete information.. Complete only the identified section(s) of the CMS 855A application that are changing.

CMS 855A	Section
CMS 855A	1	2	2B1	3	4	5	6	8	12	13	14	15
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence)	X	X	X	X						X		X
Adverse Legal Actions/Convictions	X		X	X						X		X
Practice Location Information, Payment Address & Medical Record Storage Information	X		X	X	X					X		X
Ownership Interest and/or Managing Control Information	X		X	X		X	X			X		X
Chain Home Office Information	X		X	X		X				X		X
Billing Agency Information	X		X	X				X		X		X
Special Requirements for Home Health Agencies	X		X	X					X	X		X
Authorized/Delegated Official	X		X	X			X			X		X

5. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

Mailing Address - Jurisdiction 15

CGS Administrators LLC – J15 MAC

HHH Provider Enrollment
P.O. Box 20016
Nashville, TN 37202

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:

CGS Administrators LLC – J15 MAC
26 Century Blvd STE ST610
Nashville, TN 37214-3685

Be sure to:

Complete all required information, including any boxes to indicate "not applicable".
Provide information required for Electronic Fund Transfer.
Sign your application in BLUE ink.
Date your application.
Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

3. Pay application fee

4. Complete form CMS 855A as identified below:

This tool is for those Providers with an active PECOS enrollment wanting to add, change, or delete information.. Complete only the identified section(s) of the CMS 855A application that are changing.

CMS 855A	Section
CMS 855A	1	2	2B1	3	4	5	6	8	12	13	14	15
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence)	X	X	X	X						X		X
Adverse Legal Actions/Convictions	X		X	X						X		X
Practice Location Information, Payment Address & Medical Record Storage Information	X		X	X	X					X		X
Ownership Interest and/or Managing Control Information	X		X	X	X		X			X		X
Chain Home Office Information	X		X	X			X			X		X
Billing Agency Information	X		X	X				X		X		X
Special Requirements for Home Health Agencies	X		X	X					X	X		X
Authorized/Delegated Official	X		X	X			X			X		X

5. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

Mailing Address - Jurisdiction 15

CGS Administrators LLC – J15 MAC

HHH Provider Enrollment
P.O. Box 20016
Nashville, TN 37202

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:

CGS Administrators LLC – J15 MAC
26 Century Blvd STE ST610
Nashville, TN 37214-3685

Be sure to:

Complete all required information, including any boxes to indicate "not applicable".
Provide information required for Electronic Fund Transfer.
Sign your application in BLUE ink.
Date your application.
Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

3. Complete form CMS 855A as identified below:

This tool is for those Providers with an active PECOS enrollment wanting to add, change, or delete information. Complete only the identified section(s) of the CMS 855A application that are changing.

CMS 855A	Section
CMS 855A	1	2	2B1	3	4	5	6	8	12	13	14	15
Identifying Information Ex: Legal Name Change, Doing Business As Name info, License or Correspondence)	X	X	X	X						X		X
Adverse Legal Actions/Convictions	X		X	X						X		X
Practice Location Information, Payment Address & Medical Record Storage Information	X		X	X	X					X		X
Ownership Interest and/or Managing Control Information	X		X	X		X	X			X		X
Chain Home Office Information	X		X	X		X				X		X
Billing Agency Information	X		X	X				X		X		X
Special Requirements for Home Health Agencies	X		X	X					X	X		X
Authorized/Delegated Official	X		X	X			X			X		X

4. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

Mailing Address - Jurisdiction 15

CGS Administrators LLC – J15 MAC

HHH Provider Enrollment
P.O. Box 20016
Nashville, TN 37202

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:

CGS Administrators LLC – J15 MAC
26 Century Blvd STE ST610
Nashville, TN 37214-3685

Be sure to:

Complete all required information, including any boxes to indicate "not applicable".
Provide information required for Electronic Fund Transfer.
Sign your application in BLUE ink.
Date your application.
Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.
Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.
Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

2. Have you paid the fee requirement as prescribed by CMS?

Yes No

3. Complete form 855A sections 1-8, 13, 15 16 (Optional), and 17 (Reference)

CMS 855A form

Refer to the chart below regarding Sections 5 and 6

Type of Organization	Section 5 and/or 6				Officer	Director	Managing Employee	Authorized Official	Delegated Official
Type of Organization	5% or > Direct Owner	5% or > Indirect Owner	General Partner	Limited Partner	Officer	Director	Managing Employee	Authorized Official	Delegated Official
Sole Proprietorship	A	N/A	N/A	N/A	N/A	N/A	A	A*	M*
General Partnership	M	M	A	N/A	M	M	A	A*	M*
Limited Partnership	M	M	A	A	M	M	A	A*	M*
Corporation	A	M	N/A	N/A	A	A	A	A*	M*
Limited Liability Company	A	M	N/A	N/A	M	M	A	A*	M*
Non-Profit Organization	M	M	N/A	N/A	A	A	A	A*	M*
Government Owned Entity	A	N/A	N/A	N/A	M	M	A	A*	M*
A = Applicable & required to include M = May be applicable; required to include if applicable to your organization N/A = Not applicable

*The individual(s) signing section 15 and/or section 16 must be listed as an authorized official or delegated official in Section 6.

Section 15 (Certification Statement) of the 855A must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted.

4. Include the following documents:

License, certifications and registrations required by Medicare or State Law
Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g. IRS CP575) provided in Section 2
Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit
Copy of an attestation for government entities and tribal organizations (if applicable)
Organization Structure Diagram/Flowchart identifying all entities listed in Section 5 (if Section 5A-Ownership and/or Managing Control–Organizations is applicable)

5. Electronic Funds Transfer (EFT)

EFT CMS 588 form
A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.
Please ensure your legal business name is listed on the EFT agreement and bank documentation exactly as it is with the IRS.

3. Pay application fee

4. Complete form 855A sections 1-8, 13, 15 16 (Optional), and 17 (Reference)

CMS 855A form

Refer to the chart below regarding Sections 5 and 6

Type of Organization	Section 5 and/or 6				Officer	Director	Managing Employee	Authorized Official	Delegated Official
Type of Organization	5% or > Direct Owner	5% or > Indirect Owner	General Partner	Limited Partner	Officer	Director	Managing Employee	Authorized Official	Delegated Official
Sole Proprietorship	A	N/A	N/A	N/A	N/A	N/A	A	A*	M*
General Partnership	M	M	A	N/A	M	M	A	A*	M*
Limited Partnership	M	M	A	A	M	M	A	A*	M*
Corporation	A	M	N/A	N/A	A	A	A	A*	M*
Limited Liability Company	A	M	N/A	N/A	M	M	A	A*	M*
Non-Profit Organization	M	M	N/A	N/A	A	A	A	A*	M*
Government Owned Entity	A	N/A	N/A	N/A	M	M	A	A*	M*
A = Applicable & required to include M = May be applicable; required to include if applicable to your organization N/A = Not applicable

*The individual(s) signing section 15 and/or section 16 must be listed as an authorized official or delegated official in Section 6.

Section 15 (Certification Statement) of the 855A must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted.

5. Include the following documents:

License, certifications and registrations required by Medicare or State Law
Federal, State, and/or local (city/county) business licenses, certifications and/or registrations required to operate a health facility
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g. IRS CP575) provided in Section 2. Please ensure your legal business name is listed on the application and identified with NPPES exactly as it is with the IRS.
Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit
Copy of an attestation for government entities and tribal organizations (if applicable)
Organization Structure Diagram/Flowchart identifying all entities listed in Section 5 (if Section 5A-Ownership and/or Managing Control–Organizations is applicable)

6. Electronic Funds Transfer (EFT)

EFT CMS 588 form
A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.
Please ensure your legal business name is listed on the EFT agreement and bank documentation exactly as it is with the IRS.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

Home Health & Hospice Provider Enrollment Interactive Help Tool

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