Provider Checklist

The following items will be requested of any provider completing an initial application. The items underlined are required for ANY application submission:

• CMS Medicare Provider Enrollment Application (CMS-855A)
• Completed CMS 588 Authorization Agreement for Electronic Funds Transfers
• Copy of the National Provider Identifier notification that you received from the National Plan and Provider Enumeration System
• Exhibit 177 (for FQHC Only)
• Copy of the HRSA Notice of Grant Award (for FQHC Only)
• Copy of exhibit 5 form B listing the site covered under the Grant (for FQHC Only)
• IRS document (501 (c) 3)
• Articles of Incorporation, Organization or By Laws
• DBA Certification (if applicable)
• Licenses, certifications and registration required by Medicare or State Law
• Federal, State and /or local (city/county) business licenses, certifications and/or registrations required to operate a health care facility;
• Copy of all adverse legal action documentation (e.g., notifications, resolutions and reinstatement letters)
• Copy of delegated officials W-2 (if applicable)
• Copy of an attestation for government entities and tribal organizations (if applicable)
• Copy of all applicable CLIA's (if applicable)
• A list of Board of Directors