Free Cms 1513 Form in PDF

Instructions on Writing Cms 1513

Filling out the CMS-1513 form is essential for entities that participate in health programs under titles V, XVIII, XIX, and XX. Submission of this form, which discloses ownership and control interest, is a core compliance requirement. The form seeks detailed information about the ownership and any significant changes in the entity's status that might affect its participation in federal health programs. To ensure a smooth submission process, follow these guidelines carefully. The instructions detailed here provide a straightforward approach for completing the CMS-1513 form accurately.

Steps to Fill Out the CMS-1513 Form

1. Read the general instructions carefully to understand the definitions, procedures, and requirements. These initial guidelines help you know what precise information the form is asking for.
2. Under Item I (a), provide the identifying information of the entity. Specify the capacity in which the business is conducted, whether as a corporation, partnership, or another form. Leave Item I (b) blank, as it is for Regional Office use only.
3. Answer all questions in Item II by checking "Yes" or "No". If you answer "Yes" to any question, be prepared to provide additional details in the Remarks section on page 2.
4. In Item III, list the names and addresses (or EIN for organizations) of individuals or entities with a direct or indirect ownership or controlling interest of 5 percent or more. Use the Remarks section if more space is needed.
5. Check the appropriate box in Item III (b) to indicate the type of entity. If the disclosing entity is a corporation, you'll need to list the names and addresses of the Directors under Remarks.
6. Respond to the questions in Items IV through VII about changes in provider status and ownership. If you answer "Yes" to any of these, provide the requested additional information in the Remarks section, clearly indicating to which item your information correlates.
7. For Item VIII, indicate whether there has been a bed capacity increase of 10 percent or more or by 10 beds, whichever is greater, within the last 2 years. If "Yes", specify the year of change and the number of current and prior beds.
8. Complete the declaration at the end of the form with the name and title of the authorized representative, sign, and date the document.
9. Review the completed form for accuracy and completeness. False statements can result in prosecution and may affect participation in federal health programs.
10. Retain the first copy for your records and return the original and subsequent copies to the designated State agency as instructed.

Ensuring that all relevant sections of the CMS-1513 form are filled out accurately and submitted on time is crucial for compliance with the conditions of participation in federal health services programs. Paying close attention to the detailed instructions and responding to each item thoughtfully helps avoid delays or issues with your entity's certification, recertification, or contract renewal processes.

What is the CMS-1513 form?

The CMS-1513 form, known as the Disclosure of Ownership and Control Interest Statement, is a required document for entities seeking to participate, certify, or recertify in programs under titles V, XVIII, XIX, and XX of the Centers for Medicare & Medicaid Services (CMS). It mandates the full disclosure of ownership and financial interests to ensure compliance with federal regulations. Failure to provide accurate and up-to-date information may result in the denial of participation or termination of existing agreements.

Who needs to complete the CMS-1513 form?

Any Medicare provider, supplier, or other entity that offers services or arranges for services to be furnished under Medicaid, the Maternal and Child Health program, or health-related services under the social services program must complete this form. This includes entities providing medical, remedial, or health-related homemaker services and is required annually or upon any significant change in ownership or control.

What information is required on the CMS-1513 form?

The form requires information about direct or indirect ownership interests, controlling interests, changes in provider status, and other administrative details of the disclosing entity. Specific sections include identification of the entity, listing of individuals or organizations with significant ownership or control interests, and disclosure of any changes in ownership, management, or control within the last year.

What constitutes a direct or indirect ownership interest as per the CMS-1513 form?

A direct ownership interest is defined as possession of stock, equity in the capital, or any interest in the profits of the disclosing entity. Indirect ownership interest pertains to ownership in an entity that possesses a direct or indirect interest in the disclosing entity. An ownership interest must be reported if it amounts to 5 percent or more, calculated by multiplying the percentage of ownership through each level of ownership.

How is a controlling interest defined in the context of the CMS-1513 form?

A controlling interest is the operational direction or management of the disclosing entity. It can be achieved through various methods, including the ability to amend the corporate identity, nominate board members, change operating rules, control assets, or arrange the sale or dissolution of the entity. Essentially, it refers to any authority that dictates the entity's management or operational direction.

What happens if there is a change in the information provided in the CMS-1513 form?

If there is any change in the ownership, control, or management information provided in the CMS-1513, the entity must report these changes to the State agency. This is crucial for maintaining transparency about who owns, controls, or has a significant financial interest in the provider or supplier. Changes might include a new administrator, a change in the ownership structure, or a shift in financial interests above the 5 percent threshold.

What are the implications of knowingly providing false information on the CMS-1513 form?

Submitting false statements or failing to disclose full and accurate information on the CMS-1513 form can lead to serious legal consequences, including prosecution under applicable federal or state laws. Additionally, it may result in the denial of participation in CMS programs or termination of existing contracts. Full transparency and accuracy are required to comply with federal regulations and ensure eligibility for participation in CMS programs.

When filling out the CMS-1513 form, a common mistake made by individuals is failing to provide updated and current information. This form, essential for disclosing ownership and control interests to the Department of Health and Human Services, requires accurate and up-to-date details as of the current date. Overlooking this requirement can lead to inaccuracies in the submission, resulting in potential delays or denials in participation, certification, or recertification processes. Ensuring that all provided information reflects the most current data is crucial for the efficient processing of the form.

Another frequent error occurs in the completion of Item III, where individuals and organizations must list all those with a direct or indirect ownership or controlling interest of 5 percent or more. Occasionally, entities mistakenly omit reporting indirect ownership interests that hit the 5 percent threshold. This oversight can stem from a misunderstanding of how to calculate indirect ownership, which involves multiplying the percentages of ownership interest at each ownership level. Proper calculation and reporting of these interests are imperative to meet the disclosure requirements accurately.

Incorrectly handling the changes in provider status in Items IV through VII represents another common pitfall. This section seeks information about any significant alterations in operational control, including but not limited to a change in directors or administrators, adjustments in ownership, or shifts in management entities. Individuals often check “no” without fully understanding what constitutes a change in provider status or mistakenly believe that minor changes do not need to be reported. Recognizing and accurately reporting any change in management control is essential to maintain compliance and transparency with regulatory bodies.

Last but not least, failing to properly utilize the “Remarks” section represents a missed opportunity for clarity. Respondents sometimes skip the opportunity to provide additional information when answering “yes” to certain questions, which can lead to a lack of context for the provided answers. This section is designed to offer space for elaboration and clarification, which can be particularly useful if the space provided in the main part of the form is insufficient. Utilizing this section effectively can enhance the comprehensiveness and accuracy of the information provided, facilitating a smoother review process.

Completing the Centers for Medicare & Medicaid Services (CMS) Form 1513, also known as the Disclosure of Ownership and Control Interest Statement, is a crucial step for healthcare entities seeking participation or continuation in federally funded programs. It demands transparency about the ownership and control dynamics of the entity. However, this form does not stand alone. Various other documents often accompany it, each playing a vital role in ensuring compliance and facilitating the thorough review by the appropriate agencies. In what follows, we'll explore some of these supplementary documents, shedding light on their purposes and significance.

• IRS Form W-9, Request for Taxpayer Identification Number and Certification: This form is used to provide the correct taxpayer identification number (TIN) to the party requesting it (such as a bank or employer) and, in some cases, to certify exemption from backup withholding and/or Foreign Account Tax Compliance Act (FATCA) reporting.
• Business License: A copy of the current business license demonstrates the legal right of the entity to operate within its jurisdiction. It is often required to establish credibility and compliance with local laws.
• Articles of Incorporation: For corporations, these documents establish the legal existence of the entity, outline its purpose, and specify the rules governing its internal management.
• Partnership Agreement: If the entity is a partnership, this document outlines the terms of the partnership, including details of ownership shares, the division of profits and losses, and management responsibilities.
• Bylaws or Operating Agreement: This document provides the internal rules for the management and administrative operations of the entity. For corporations, these are bylaws; for LLCs, an operating agreement.
• Proof of EIN: The Employer Identification Number (EIN), obtained from the IRS, is crucial for tax administration for entities. A document confirming the EIN is often required.
• Professional Licenses: For entities providing professional services, such as healthcare, proof of the professional licenses of practitioners or the entity itself validates their legal and professional standing to provide such services.
• Medicare or Medicaid Program Participation Agreements: Copies of any current agreements with Medicare or Medicaid illustrate the entity’s standing and participation status with these programs.
• Financial Statements: Recent financial statements offer insights into the financial health and stability of the entity, which can be crucial for audits and compliance assessments.
• Lease Agreements or Deeds: Documents proving the entity's legal right to occupy its business premises, whether through ownership or lease, are necessary for verifying the physical location of the business.

While the CMS 1513 form serves as a critical starting point for disclosing ownership and control interests, the accompanying documents provide a comprehensive view of the entity's legal, financial, and operational standing. Collectively, these documents facilitate a thorough and efficient review process, ensuring entities meet the regulatory requirements essential for participating in federally funded healthcare programs. Understanding the context and requirements for each document is fundamental for compliance and successful participation in these programs.

The CMS-855A form, like the CMS-1513, is specifically designed for Medicare service providers. Both forms require detailed information about the ownership, control interests, and management structure of the entities applying for Medicare certification or looking to maintain their current provider status. While the CMS-1513 form focuses on disclosing ownership and control interests to ensure compliance with health program requirements, the CMS-855A specifically targets providers of medical or health services, requiring them to report similar information as a condition of participation in Medicare.

The OGE Form 450 closely mirrors the principles of the CMS-1513 form, emphasizing transparency and ethical conduct within federal agencies. While the CMS-1513 requires healthcare entities to disclose ownership and control interests possibly affecting Medicare and Medicaid participation, the OGE Form 450 is used by federal employees to reveal any potential conflicts of interest, including financial interests that could influence their official duties. The underlying goal of both forms is to prevent conflicts of interest and ensure integrity in operations and decision-making processes.

The CMS-855B form is analogous to the CMS-1513 in its purpose for suppliers of medical equipment, prosthetics, orthotics, and supplies (DMEPOS) aspiring to engage in Medicare. Both documents mandate comprehensive disclosure of ownership, administrative structure, and control to mitigate fraud and abuse within the Medicare program. However, the CMS-855B specifically addresses the requirements and qualifications for DMEPOS suppliers, ensuring they are responsible and properly structured to provide equipment and supplies to Medicare beneficiaries.

SEC Form D shares a similar objective with the CMS-1513, focusing on the transparency of ownership and control, albeit within the context of securities. The SEC Form D is a filing requirement for companies seeking exemption from full SEC registration when they offer and sell securities. Like the CMS-1513's goal of disclosing ownership to prevent conflicts of interest in healthcare, Form D aims to protect investors by providing essential information about the company's key stakeholders and their financial stakes.

The IRS Form 990 is used by tax-exempt organizations to provide the IRS with annual financial information, paralleling the CMS-1513 form’s objective of ensuring transparency in entities’ operations. While Form 990 focuses on the financial activities, governance, and compliance of nonprofit organizations with tax laws, the CMS-1513 ensures that healthcare providers and suppliers disclose their ownership and control structures to comply with federal health program integrity requirements. The core similarity lies in both forms' roles in promoting accountability and transparency.

Lastly, the CMS-855I form, much like the CMS-1513, is tailored for individual practitioners and physician groups that intend to participate in the Medicare program. Both forms necessitate detailed disclosures about ownership and financial interests to ensure that participants in federal healthcare programs operate with integrity and are free from conflicts of interest. While the CMS-855I is targeted toward individual providers, ensuring their eligibility and credentials, it aligns with the CMS-1513’s broader goal of maintaining transparency and ethical conduct within the healthcare system.

When filling out the CMS-1513 form, it is important to pay attention to both the instructions provided and the accuracy of the information submitted. Below is a list of dos and don'ts to consider:

• Do answer all questions as of the current date to ensure the provided information is up-to-date.
• Do check the "yes" box for any item that is applicable and list the requested additional information under the Remarks section, clearly referencing the item number.
• Do use an attached sheet if additional space is needed, ensuring it is clearly marked and easy to associate with the main form.
• Do return the original and second and third copies to the State agency and retain the first copy for your records.
• Do report any substantial delays in completing the form to the State survey agency immediately.
• Don't overlook the requirement to disclose full and accurate information about ownership and financial interest; failure to do so may lead to severe consequences.
• Don't skip any sections that apply to you; Title XX providers and Title V providers have specific parts of the form that must be completed.
• Don't forget to list all individuals and organizations with a direct or indirect ownership or controlling interest of 5% or more.
• Don't make or cause to be made any false statement or representation on this form, as it may result in prosecution under applicable federal or state laws.

• One common misconception is that the CMS-1513 form is only for healthcare providers. While it primarily concerns Medicare providers, suppliers, and other entities under Medicaid or health programs, the requirement extends beyond just direct healthcare provision. This encompasses any entity that has financial transactions or contracts with the Department of Health and Human Services (HHS) under various titles, ensuring transparency in ownership and financial interests.

• Another misconception is that the CMS-1513 form is optional or only needed for initial certification. In reality, this form is mandatory for participation, certification, or recertification under the healthcare programs specified by titles V, XVIII, XIX, and XX. Moreover, it must be completed annually or upon any significant change in ownership or control, emphasizing its continual importance beyond initial engagement.

• Some believe that disclosing only direct ownership interests is sufficient when completing the form. However, the form requires disclosure of both direct and indirect ownership interests of 5 percent or more in the disclosing entity. This includes any interest an individual or organization has in an entity that itself has any level of interest in the disclosing entity, ensuring a comprehensive view of financial interests and control.

• There is a misconception that if you don't anticipate any changes in ownership or control, you don't have to pay much attention to the form after the first submission. This overlooks the form's design to capture and update any changes in provider status, such as changes in management, operational control, or financial interest, that must be reported as they occur.

• Finally, some assume that the details around chain affiliation are only relevant if the facility is currently part of a chain. However, the CMS-1513 form requires information about past affiliations and changes in capacity or facility status, including any past affiliations with chains or significant changes in service capacity. This comprehensive historical perspective ensures that the Centers for Medicare & Medicaid Services (CMS) has a full understanding of an entity's operational history and potential changes affecting its service provision.

Filling out and utilizing the CMS-1513 form, officially titled the Disclosure of Ownership and Control Interest Statement, involves detailed procedures that individuals and organizations must follow to comply with regulations set by the Centers for Medicare & Medicaid Services (CMS). Here are four key takeaways regarding this process:

• The completion and submission of the CMS-1513 form is mandatory for participation, certification, or recertification under healthcare programs established by titles V, XVIII, XIX, and XX. It serves as a condition for entering or renewing a contract with the Secretary of the appropriate State agency. The form requires disclosing full and accurate details of ownership and financial interests.
• Applicants must provide precise information about direct and indirect ownership interests or controlling interest in the disclosing entity. This includes detailing any individual or organization with a 5 percent or more stake, whether direct or indirect. The form is designed to disclose financial interests transparently to prevent conflicts of interest and ensure program integrity.
• Changes in provider status, such as changes in management, ownership, or operational control, must be immediately reported through the CMS-1513 form. This ensures that CMS has up-to-date information on entities under its programs, assisting in administrative and regulatory compliance.
• The form requires annual completion and any substantial delay in its submission should be reported to the State survey agency. Failure to provide requested information or knowingly and willfully making false statements may lead to prosecution under applicable federal or state laws, and could result in the denial of participation or termination of existing agreements or contracts.

Significant for entities and individuals involved in healthcare provision under federally supported programs, the CMS-1513 form plays a critical role in maintaining transparency and ethical standards within the healthcare system.