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Systems Design West, LLC 2020-02-20
NaviNet Provider Entity Authorization Form for NaviNet Billing Agency Access NaviNet is required to implement reasonable administrative and technical safeguards before it can provide the billing agency below (business associate)access to patient information held by you the provider entity(covered entity.) Type or print all needed information. This is to advise NaviNet that I City of Ukiah (Provider Entity/Provider Office Name)has appointed Systems Design West LLC Pp (Billing Agency Name)as our billing agent. This billing agency should be given access to NaviNet to view all information needed for the research,submission,and adjustment of claims;collection and follow up matters;determination of eligibility and benefits;as well as any other routine billing agency functions. This access will allow the billing agent to conduct billing related work on behalf of your provider organization with various health plans within NaviNet. This authorization form will enable the billing agency listed above access to all present and future health plans available to your provider organization within NaviNet. Provider entity confirms that the billing agency has signed a written agreement pursuant to which it has agreed to treat any information it receives from the provider office(via NaviNet or otherwise)as confidential,and in accordance with all applicable laws and regulations. Further,in consideration of NaviNet's acceptance of the billing agency,the provider entity agrees that it will indemnify and hold NaviNet harmless for any and all damages,claims and expenses that NaviNet may incur or that may be asserted against NaviNet as a result of the negligent or intentional actions of the billing agency in carrying out its duties with the purposes noted above. NaviNet shall be entitled to rely on this letter until revoked in writing. (tor example,it is the provider entity's responsibility to notify NaviNet of the termination of or a change in its relationship with the billing agency.) The signatures below indicate acceptance by both parties of all conditions outlined in the above paragraphs. Please Note: Signatures are required from a Billing Agency employee and an employee from the Provider Entity/Provider Office. A Billing Agency employee cannot sign on behalf of the Provider Entity/Provider Office. To be completed by the Provider Office Provider Entity/Provider Office Tax ID Provider Entity/Provider Office Group Name 9 4 ®L] a a FA] I City of Ukiah Authorized Em to ee or NaviNet Security Officer)Name Authorized Employee Telephone Number Sage Sangiacomo (707) 462-7921 Siignature of Authorized Em to ee Date c� To be completed by the Billing Agency Authorized Employee or NaviNet Security Officer)Name Authorized Employee Telephone Number Kelsey Ross (360) 394-7052 Signature of Authorized Employee Date When the form is complete and all signatures are obtained,please fax to 617-418-6540, Attention:NaviNet Billing Agency. Pmv. 11, "1 * = required field I CONFIDENTIAL InstaMed -------�--- 1¢ INSTAMED ORDER FORM - PAYER PAYMENTS Healthcare Payments Simplified t Get paid faster and easier with ERA/EFT. Online Instructions Send through secure fax: Review and complete entire form Sign signature field(s) (877)755.3392 or mail: to Is is PO Box 58790 Philadelphia,PA 19102 Incomplete forms will not be accepted SOLUTION DESCRIPTION By registering for Payer Payments,you will receive payments from the payers listed at the fofrowfng URL(hitpy/Inro.rnstamed.00m/payerpaymenm payer4ist)by electronic funds transfer(EFT)and claims information by electronic remittance advice(ERA)AReryou register for Payer Payments,you will no longer receive a paper check or paper explanation of payment(EOP)from the payers listed at the URL set forth In the prior sentence,which URL InstaMed may update from time to time to add or remove payers.To opt out of Payer Payments from one or more of the available payers,please contact InstaMed at(866)945-7990 or connect®instamed.com. CUSTOMER INFORMATION Primary Contact Billing Address Douglas Hutchison City of Ukiah Name(First/Last) Customer Legal Name Fire Chief Ukiah Valley Fire Authority Title Customer DBA Name(If different) 707-462-7921 1500 South State Street Phone Street Line 1 dhutchison@cityofukiah.com Email Street Line 2 Ukiah CA 95482-6709 cc City State Zip • 94-6000446 Number of Providers Tax 1D Patient Accounting System Version • Remittance Delivery You will automatically receive ERAS through the InstaMed secure Provider Portal.To receive ERAS through your clearinghouse,please list your clearinghouse below.For a list of supported clearinghouses for ERA,visit:www.instamed.com/eraclearinghouses. Clearinghouse: ZirMed, Inc ❑Check this box to receive ERAS via SFTP(Secure File Transfer Protocol) NPIS Please give your Billing Provider NPI(s)and,If you use Service Provider NPI(s)for claims billing,please list them also.If your Practice does not use Service Provider NPI(s)for claims billing,you do not need to list them.In order to avoid misdirected payments,only list NPI(s)that should have ALL of their remittances and payments routed to you.Do not include NPI(s)that also do business under other healthcare providers. Billing Provider NPI: 1114560984 Billing Provider NPI: Billing Provider NPI: Billing Provider NPI: Internal initials: HB 20160825 www.instamed.com I connect@instamed,corn i (MC)945-7990 1 of-Z i n sta M ed I CONFIDENTIAL INSTAMED ORDER FORM - PAYER PAYMENTS Healthcare Payments Simplified BANK ACCOUNT INFORMATION Bank account information is required for payer payment deposits.A voided check or bank letter is required. Umpqua Bank 123205054 10604605 Bank Name Routing Number Account Number cc IL IOHN SWTH 1234 1334 MAIN ST PHILAUMPHIA.PA 191113 • A77 U FAY TO TORDER OFF `. LXJLLARS piP Routing Number Account Number r:0001234491: 143902040r' 1234 AGREED AND ACCEPTED By signing below,y-u agree to the terms of this Order Form and you confirm that the other-nforr ation that you have pr.)v ded in the Order Form is true and correct. You also agree to the Terms and Conditions set forth at www.instamed,corn/irrwnline/terms_and_condfions.htmi or separately agreed to in writing by you and Instamed.which are integral to,and form a part of,this Order Form. The part as consent and agree that this Order Form may be electronically signed.The parties agree the electronic signatures appearing on this Order Form are the same as handwritten signatures for purposes of validity,enrorceability and admissibility. City of Ukiah Customer Legal Name 94-6000446 Tax ID(same as page 1) sign,gur4—# Date Sage angiacomo Print Name City Manager Title Internal Initials- HB 20160825 wwminstamed.com t cannect@instanted.com (866)945-7990 201 C� CONFIDENTIAL InstaMed ry Billing Service—Account Access Form(Paper Registration) Healthcare Payments Simplified Billing Service—Account Access Form (Paper Registration) Please complete this form in order to authorize InstaMed to transfer access to Provider's processing information to Provider's Billing Service, Upon InstaMed's receipt and handling of a completed form, Provider will be required to contact Billing Service for access to Provider's processing information and remittance data. The form must be completed and signed by both Billing Service and Provider. Provider may revoke the authorization at any time upon the delivery of written notice to InstaMed. Please send your completed form to: • Email:conneeMinstamed.com or • Fax;(877)756.3392 If you have any questions,do not hesitate to contact us at connecMinstamed.com or(866)945-7990. SECTION ONE—BILLING SERVICE AUTHORIZATION This section is to be completed by the Billing Service. Organization Name: Systems Design West,LLC Corporate ID. SDWEMS Contact Name: Kelsey Ross Phone Number: (360)394-7052 Email: KelseyR@SDWems.com Signature: Date: Print Name: Kelsey Ross SECTION TWO— PROVIDER AUTHORIZATION This section is to be completed and signed by the Provider. By signing below, Provider authorizes InstaMed to transfer access to Providers processing information and remittance data to Provider's Billing Service. Upon InstaMed's receipt and handling of a completed form. Provider will be required to contact Billing Service for access to Provider's processing information and remittance data. Organization Name- City of Ukiah Tax ID Number: 94-6000446 NPi Number(s). 1114560984 Contact Name: Sae San iacomo Phone Number 707 462-792i Email. ssan iacomo ci ofukiah.ccm S-.gnature Date- d —aCPQ%b Prnt Name: Sa a San iacomo v2a15a1a7 ,D 2016 InstaMed. All rights reserved. COU No. )4t 2,0`2.10 Company Code:270 _ (Shaded areas are for internal use only) point&pay Client Application Partner Code: Account Representative: SubmissionDate: F _ Card Readers: �T Target Live Quanti : �.-.r..- Price perreader: Date: Client Legal Federal Tax ID: City of Uki Please select one fee option for your Point& Pay 94-6000446 DBA: account: --- 7 Physical Ad 1. Fee Absorbed by Partner: 2.50%of the patient's payment amount. Payment amount must be at City: State: CA xi feast $2.00. Point & Pay will invoice you once a p: 95482-6709 Website Ad month,OR #to display on customer receipts: 800-238-9398 2. Fee Paid by Customer. 2.95% of the payment Prima Con (same $2.00 minimum). Point & Pay adds this to #: _ Primary Email: the transaction and takes It right from the patient's 7-462_7921 dhutchison@cityofukiah.com bank,at no cost to you. Accountin ne#: Accounting Email: 60-394-7059 rachelled@sdwems.com ❑� Electronic Check 1.❑ Fees Absorbed by Client 2. ❑ Fees Paid by Customer 3.❑Tiered Fees 1.Absorbed Credit Card Fees: 1.Payment Method For Monthly Billing: 1.Absorbed E-check Fees: 1. Utility Program(Absorbed) ❑Debit 1. Billing Contact Info:� El Mail In Check Online Credit Card 2. Credit Card-Flat Fee $ Debit Card-Fiat Fee $ ❑Credit Card-Percentage Fee } MCredit Card-Minimum Fee $2- L 2.El E-check-Flat Fee $a.00 ❑Credit Card-Chargeback Fee $ 3.Credit Card- Tiered Fees: Fee=$ for payments between$0.01 to$50.00 Fee=$ for payments between$50.01 to$100.00 Fee=$ for payments between$100.01 to$150.00 Fee=$ for payments between$150.01 to$200.00 Fee=$ for payments between$200.01 to$250.00 Fee=$ for payments between$250.01 to$300.00 Fee of an additional$ for payments between the next$50 range as outlined i Fee=$ for payments between$0.01 to$100.00 Fee=$ for payments between$100.01 to$200.00 Fee=$ for payments between$200.01 to$300.00 Fee=$ for payments between$300.01 to$400.00 Fee=$ for payments between$400.01 to$500.00 Fee=$ for payments between$500.01 to$600.00 Fee of an additional$ for payments between the next$100 range as outlined Software Partner:(SP) Yes ■No If Yes,Software Partner(SP)Name and Contact Info:: T ' Type of integration;..._ Yes ■ No - - r2.2W Averaae Highest Product Name Channel Annual Payment Payment collectlons Am9wrt 1 EMS Transport Fees PNP POS PNP IVR ■PNP WEB $ $300.00 $1500.00 _ SP POS [3(SP)WEB BILL PAY 2 PNP POS LJPNP IVR PNP WEB $ $ $ ❑ SP POS SP WEB❑BILL PAY 3 E:IPNP POS UPNP IVR LIPNP WEB $ $ $ SP POS SP WEB❑BILL PAY ❑PNP POS ❑PNP IVR ❑PNP WEB❑ $ $ $ SP POS SP WEB❑BILL PAY PNP POS UPNP IVR PNP WEB ❑ SP POS ❑SP WEB❑BILL PAY $ $ $ PNP POS PNP IVR PNP WEB ' ❑ SP ❑POS SP WEB❑BILL PAY $ $ $ PNP POS LJPNP IVR PNP WEB SP POS ❑ SP WEB❑BILL PAY $ $ $ ❑ S _ LJPNP POS LJPNP IVR LJPNP WEB $ $ $ ❑ SP POS ❑ SP WEB❑BILL PAY PNP POS PNP IVR PNP WEB 8 _ ❑ SP ❑POS SP WEB❑BILL PAY $ $ $ PNP POS PNP IVR PNP WEB 1t} ❑ SP POS ❑ SP WEB❑BILL PAY $ $ $ Deoosit Structure: ❑Net Settlement ❑■Debit If Debit: ■❑Same account in which funds were de osited ❑Use specific account ending in oducName or#from Bank Name Routina# Account# EMS Transport Fees Umpqua Bank 123205054 10604605 ❑■Checking ❑Savings ❑Checking ❑Savings ❑Checking []Savings ❑Checking ❑Savings ❑Checking ❑Savings ❑Checking ❑savings ❑Checking ❑Savings ❑Checking ❑Savings ❑Checking ❑Savings ❑Checking ❑savings The undersigned agrees to abide by the Terms and Conditions of the Global Merchant Services Agreement,viewable at www.aointan_dpay.com/agreement. City Manager Signature Title Sage Sangiacomo Q - Name Hate COU No. Modifled 02/27/2015 VA I ll.fi. IkIui�tmrnt of Veft-wins Affair; DEPARTMENT OF VETERANS AFFAIRS VISN 20 Northwest Network Payment Center PO Box 1035 • Mail Stop: I ON20 Portland,OR 97207 Dear Non-VA Medical Care Provider, Please complete the following information so that we can properly create/update your account for payment processing.If you have any questions,please contact the Network Payment Center at(360)696-4061,extension 34225 or 34224. Name(as recorded with SSN or TIN): City of Ukiah Business name,if different from above: Ukiah Valley Fire Authority Billing Address: PO Box 3510 City: Silverdale County: Kitsap State: WA Zip Code: 98383-3510 Phone Number: (360)394-7020 FAX: (360)394-7099 Specialty: Ground Ambulance Transport Provider NPI: 1114560984 (*' Tax ID or (- SSN: 946000446 Medicare ID Number: Business type:(select one) Special categories within business type:(check all that apply) Q Small Business-a business whose gross annual receipts F Vietnam Veteran-Owned,51%or more owned by a average$5 million or less for the last 3 years. Vietnam-era Veteran Q Large Business-a business whose gross annual receipts F Disabled Veteran-Owned,51%owned by a Disabled Veteran over$5 million for last 3 years. r Veteran-Owned,51%owned by a Veteran Q Outside the United States r Veteran-Owned O Other entities,including state/local Government, r Disadvantaged,51%or more owned by one or more socially educational or nonprofit or economically disadvantaged individuals,including Black Americans,Hispanic Americans,Native Americans and Asian-Pacific Americans r Historically Black College&University Minority Institution r Woman-Owned,51%or more owned by I or more women r Woman-Owned r Javits-Wagner-O'Day - -a�aa Signature of compiky official Date FAX FORM TO:(360)905-17721 ATTN: NETWORK PAYMENT CENTER 1 SITE: ACH VENDOR/MISCELLANEOUS PAYMENT OMB No. 1510.0056 ENROLLMENT FORM This form is used for Automated Clearing House (ACH) payments with an addendum record that contains payment-related information processed through the Vendor Express Program. Recipients of these payments should bring this information to the attention of their financial institution when presenting this form for completion. See reverse for additional instructions. PRIVACY ACT STATEMENT The following information is provided to comply with the Privacy Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR 210. This information will be used by the Treasury Department to transmit payment data, by electronic means to vendor's financial institution. Failure to provide the requested information may delay or prevent the receipt of payments through the Automated Clearing House Payment System. AGENCY INFORMATION FEDERAL PROGRAM AGENCY U.S. Department of Veterans Affairs - Financial Services Center AGENCY IDENTIFIER: AGENCY LOCATION CODE{ALCI: ACH FORMAT: 111036183 36001200 1171 CCDt CTX ADDRESS: P.O. Box 149971 Austin TX 78714-8971 CONTACT PERSON NAME: TELEPHONE NUMBER: Customer Support Help Desk - Vendorizin Team ( 877 353-9791 ADDITIONAL INFORMATION: Fax completed form to (512) 460-5221 PAYEE/COMPANY INFORMATION NAME SSN NO.OR TAXPAYER ID NO. City of Ukiah 1946000446 ADDRESS PO Box 3510 Silverdale, WA 98383-3510 CONTACT PERSON NAME: TELEPHONE NUMBER: Sage Sangiacomo 707 ) 462-7921 FINANCIAL INSTITUTION INFORMATION NAME: Umpqua Bank ADDRESS: 607 S State Street. Ukiah, CA 95482 ACH COORDINATOR NAME: TELEPHONE NUMBER: Shauna Rotbergs ( 707 467-2241 NINE-DIGIT ROUTING TRANSITWUMBER: 1 2 3 2 0 5 0 5 4 DEPOSITOR ACCOUNT TITLE: City of Ukiah DEPOSITOR ACCOUNT NUMBER: LOCKBOX NUMBER: 10604605 TYPE OF ACCOUNT: X CHECKING SAVINGS LOCKBOX SIGNATURE AND TITLE OF AUTHORIZED OFFICIAL: TELEPHONE NUMBER: {Could be the same as ACHCo rdinatori J` ( 707 ) 462-7921 AUTHORIZED FOR L CAL REP DUCTION (Rev.212003 Prescribed by De ■rtment of Treasury 31 U S C 3322:P1 CFR 210 Instructions for Completing SF 3881 Form Make three copies of form after completing. Copy 1 is the Agency Copy; copy 2 is the Payee/Company Copy; and copy 3 is the Financial Institution Copy. 1. Agency Information Section - Federal agency prints or types the name and address of the Federal program agency originating the vendor/miscellaneous payment, agency identifier, agency location code, contact person name and telephone number of the agency. Also, the appropriate box for ACH format is checked. 2. Payee/Company Information Section - Payee prints or types the name of the payee/company and address that will receive ACH vendor/miscellaneous payments, social security or taxpayer ID number, and contact person name and telephone number of the payee/company. Payee also verifies depositor account number, account title, and type of account entered by your financial institution in the Financial Institution Information Section. 3. Financial Institution Information Section - Financial institution prints or types the name and address of the payee/company's financial institution who will receive the ACH payment, ACH coordinator name and telephone number, nine-digit routing transit number, depositor (payee/company) account title and account number. Also, the box for type of account is checked, and the signature, title, and telephone number of the appropriate financial institution official are included. Burden Estimate Statement The estimated average burden associated with this collection of information is 15 minutes per respondent or recordkeeper, depending on individual circumstances. Comments concerning the accuracy of this burden estimate and suggestions for reducing this burden should be directed to the Financial Management Service, Facilities Management Division, Property and Supply Branch, Room B-101, 3700 East West Highway, Hyattsville, MD 20782 and the Office of Management and Budget, Paperwork Reduction Project (1510-0056), Washington, DC 20503. OM8 Approved No.2900-OW Respondent Burdcn:15 Minutes Ex uatian Date,07-31-2019 7��NEW VA-FSG VENDOR FILE REQUEST FORM DATE UPL7ATEdRMATION PAYEENENDOR INFORMATION STATION NUMBER ❑COMMERCIAL VENDOR REGISTERED IN 3AM.GOV (Required IAW FAR 4.1102) STATION CONTACT DUNS NUMBER STATION PHONE NUMBER STATION FAX NUMBER DUNS+4 STATION EMAIL ADDRESS SSN(rIN 946000446 PAYEEIVENDOR TYPE(Select one) NPI C-COMMERCIAL EIF-FEDERAL AGENCY 1114560984 E-EMPLOYEE 0-FOREIGN FACTS ID SMALL BUSINESS-VENDOR MUST BE QUALIFIED AS SMALL BUSINESS IN I-INDIVIDUALMONORARIUM A-AGENT CASHIER SAM OR FURNISH SBA CONFIRMATION _VENDOR NAME �V-VETERAN �U-UTILITY City Of Ukiah MISCELLANEOUS ACTIONS(Select one) DBA FIWINRS ASSIGNMENT(A11wplicaLledoc mentV Ukiah Valley Fire Authority 11 BILL OF COLLECTIONS SETTLEMENTIrORTS CONTACT 0ALACILGY ACCOUNT It Sage Sangiacomo EMAIL ADDRESS ssangiacomo@cityofukiah.com FOR QUESTIONS REGARDING THIS FORM: PHONE NUMBER CO N=I N FOR MAT I ON' (707) 462-7921 VENDOR CUSTOMER SERVICE SUPPORT HELPDESK: CURRENT ADDRESSS(Lrclude Street,City,State and Zip Code) PO sox 3510 PHONE: 512-460-5049 Silverdale, WA 98383-3510 EMAIL VAFMC,SHD9DVA.GOV-GOV FOR ALL OTHER INQUIRIES: CUSTOMER CARE CENTER: 1-877-353-9781 PREVIOUS ADDRESSS(Inclu*Savet.City,State andZtp Code) STATION CARE CENTER: 1-866-372-1141 SUBMIT ALL DOCUMENTATION VIA: SECURE FAX: 512-460.5221 EFTIACH(Required IAw3)CFR Par(308) BANK NAME Umpqua sank '---"' R19K-ItDDRESSS r�1�rk—Clllr,-�c��2tp-C+Tt1�`-- 607 South State Street: Ukiah, CA 95482 NINE-DIGIT BANK ROUTING NUMBER 123205054 ACCOUNT NUMBER PRIVACY ACT STATEMENT The following information is provided to comply with the Privacy 106 04 6 0 5 Act of 1974 (P.L. 93-579). All information collected on this form is required under the provisions of 31 U.S.C. 3322 and 31 CFR ACCOUNTTYPE 210.This information will be used by the Treasury Department to ❑X CHECKING SAVINGS transmit payment data, by electronic means to vendor's financial NAME AND TITLE OF PAYEEIVENDOR institution, Failure to provide the requested information may delay Sage Sangiacomo, City Manager or prevent the receipt of payments through the Automated for City of Ukiah Clearing House Payment System. SIGNATURE OF PAYEENENDOR NORMAL PROCESSING TIME IS 3-5 BUSINESS dAY§__AVE DO NOT ACCEPT INVOICES VAFORM AUG 2016 10091 Kelsey Ross From: notification@pay.gov Sent: Thursday,January 16, 2020 11:45 AM To: dhutchison@cityofukiah.com; Kelsey Ross Subject: Pay.gov Payment Confirmation: Medicare Application Fee CAUTION:This email originated from outside of the organization. Do not click links or open attachments unless you recognize the sender and know the content is safe. Your payment has been submitted to Pay.gov and the details are below. If you have any questions or you wish to cancel this payment, please contact Pay.gov Customer Service by phone at(800) 624-1373 or by email at pay.gov.clev@clev.frb.org. Application Name: Medicare Application Fee Pay.gov Tracking ID: 26MS07A3 Agency Tracking ID: 16343770967220061 Transaction Type:Sale Transaction Date:Jan 16, 2020 2:45:03 PM Account Holder Name: Ukiah Valley Fire Authority Transaction Amount:$595.00 Card Type:Visa Card Number: ***********w2958 THIS IS AN AUTOMATED MESSAGE. PLEASE DO NOT REPLY. z COU No. I a SECTION 1: BASIC INFORMATION ALL APPLICANTS MUST COMPLETE THIS SECTION (See instructions for details.) A. Check one box and complete the required sections. REASON FOR APPLICATION BILLING NUMBER INFORMATION REQUIRED SECTIONS *You are a new enrollee in Enter your Medicare Identification Complete all applicable Medicare Number(if issued)and the NPI you sections would like to link to this number in Ambulance suppliers must Section 4. complete Attachment 1 IDTF suppliers must complete Attachment 2 ❑You are enrolling in Enter your Medicare Identification Complete all applicable another fee-for-service Number(if issued)and the NPI you sections contractor's jurisdiction would like to link to this number in Ambulance suppliers must Section 4. complete Attachment 1 IDTF suppliers must complete Attachment 2 ❑You are reactivating your Enter your Medicare Identification Complete all applicable Medicare enrollment Number(if issued)and the NPI you sections would like to link to this number in Ambulance suppliers must Section 4. complete Attachment 1 Medicare Identification Number(s) IDTF suppliers must complete (if issued): Attachment 2 National Provider Identifier(if issued): ❑You are voluntarily Effective Date of Termination: Sections 1,2B1, 13,and either terminating your 15 or 16 Medicare enrollment. (This Medicare Identification Number(s)to If you are terminating an is not the same as "opting Terminate (if issued): employment arrangement out" of the program) with a physician assistant, National Provider Identifier(if issued): complete Sections JA,2G, 13, and either 15 or 16 CMS-8558(07111) 4 SECTION 9: BASIC INFORMATION (Continued) ALL APPLICANTS MUST COMPLETE THIS SECTION (See instructions for details.) A. Check one box and complete the required sections. REASON FOR APPLICATION BILLING NUMBER INFORMATION REQUIRED SECTIONS ❑You are changing your Medicare Identification Number: Go to Section 1 B Medicare information National Provider Identifier(if issued): ❑You are revalidating your Enter your Medicare Identification Complete all applicable Medicare enrollment Number(if issued) and the NPI you sections would like to link to this number in Ambulance suppliers must Section 4. complete Attachment 1 Medicare PTAN: IDTF suppliers must complete NPI: Attachment 2 CMS-855B(07111) 5 SECTION 1: BASIC INFORMATION (Continued) B. Check all that apply and complete the required sections: REQUIRED SECTIONS 1,2(complete only those sections that are changing), 3,13,and either 15 (if you are an authorized official) F1 Identifying Information or 16 (if you are a delegated official), and 6 for the signer if that authorized or delegated official has not been established for this supplier 1,2B1,3,13,and either 15 (if you are an authorized 0 Final Adverse Actions/Convictions official) or 16 (if you are a delegated official), and 6 for the signer if that authorized or delegated official has not been established for this supplier 1,2B1,3,4 (complete only those sections that are [R) Practice Location Information, Payment changing),13,and either 15 (if you are an authorized Address & Medical Record Storage official) or 16 (if you are a delegated official), and Information 6 for the signer if that authorized or delegated official has not been established for this supplier ❑ Change of Ownership (Hospitals, Portable Complete all sections and X-Ray Suppliers & Ambulatory Surgical provide a copy of the sales agreement Centers Only) 1,2B1,3,5,13,and either 15(if you are an authorized 0 Ownership Interest and/or Managing official) or 16 (if you are a delegated official), and 6 Control Information (Organizations) for the signer if that authorized or delegated official has not been established for this supplier 1,2B1,3,6,13,and either 15 (if you are an authorized 19 Ownership Interest and/or Managing Control official) or 16 (if you are a delegated official), and 6 Information (Individuals) for the signer if that authorized or delegated official has not been established for this supplier 1,2B1,3,8 (complete only those sections that are changing),13,and either 15(if you are an authorized 0 Billing Agency Information official) or 16 (if you are a delegated official), and 6 for the signer if that authorized or delegated official has not been established for this supplier 1,2B1,3, 13, 15 or 16 (if you are a delegated 0 Authorized Official(s) official),and 6 for the signer if that authorized or delegated official has not been established for this supplier 1,2B1,3, 13, 15, 16,and 6 for the signer if that 0 Delegated Official(s) (Optional) delegated official has not been established for this supplier. CMS-8558(07/11) 6 SECTION 1: BASIC INFORMATION (Continued) ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS (ONLY) REQUIRED SECTIONS 1,2B1,3, 13,and 15 if you are the •Geographic Area authorized official or 16 if you are the delegated official Attachment 1(A) 1,2131,3, 13,and 15 if you are the • State License Information authorized official or 16 if you are the delegated official Attachment 1(B) 1,2B1,3, 13,and 15 if you are the 17 Paramedic Intercept Services Information authorized official or 16 if you are the delegated official Attachment 1(C) 19 2B1,3, 13,and 15 if you are the 19 Vehicle Information authorized official or 16 if you are the delegated official Attachment 1(D) ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING REQUIRED SECTIONS FACILITIES (ONLY) 1,2B1,3, 13,and 15 if you are the ❑CPT-4 and HCPCS Codes authorized official or 16 if you are the delegated official Attachment 2(B) 19 2B1,3, 13,and 15 if you are the ❑ Interpreting Physician Information authorized official or 16 if you are the delegated official Attachment 2(C) 1,2B1,3, 13,and 15 if you are the ❑ Personnel (Technicians) Who Perform Tests authorized official or 16 if you are the delegated official Attachment 2(D) 1,2B1,3, 13,and 15 if you are the ❑ Supervising Physician(s) authorized official or 16 if you are the delegated official Attachment 2(E) 1,2B1,3, 13,and 15 if you are the ❑ Liability Insurance Information authorized official or 16 if you are the delegated official Attachment 2M CMS-855B(07111) 7 SECTION 2: IDENTIFYING INFORMATION A. Type of Supplier Check the appropriate box to identify the type of supplier you are enrolling as with Medicare. If you are more than one type of supplier, submit a separate application for each type. If you change the type of service that you provide (i.e., become a different supplier type), submit a new application. Your organization must meet all Federal and State requirements for the type of supplier checked below. TYPE OF SUPPLIER: (Check one only) 9)Ambulance Service Supplier ❑Mass Immunization (Roster Biller Only) ❑Ambulatory Surgical Center Clinic/ ❑ Pharmacy Group Practice ❑ Physical iOccupationai Therapy Group in ❑Hospital Department(s) Private Practice ❑Independent Clinical Laboratory ❑Portable X-ray Supplier ❑ Independent Diagnostic Testing Facility ❑Radiation Therapy Center ❑ Intensive Cardiac Rehabilitation ❑Other(Specify): ❑Mammography Center B. Supplier Identification Information 1. BUSINESS INFORMATION Legal Business Name (not the "Doing Business As" name)as reported to the Internal Revenue Service _City of Ukiah Tax Identification Number 88-0193180 Other Name Type of Other Name Ukiah Valley Fire Authority ❑Former Legal Business Name ❑X Doing Business As Name ❑Other (Specify): Identify how your business is registered with the IRS. (NOTE: If your business is a Federal and/or State government provider or supplier, indicate "Non-Profit" below.) ❑ Proprietary 9 Non-Profit NOTE: If a checkbox indicating Proprietary or non-profit status is not completed, the provider/supplier will be defaulted to "Proprietary." Identify the type of organizational structure of this provider/supplier (Check one) ❑Corporation ❑ Limited Liability Company ❑Partnership ❑Sole Proprietor 9 Other (Specify): Municipality Incorporation Date(mm/ddlyyyy)(if applicable) State Where Incorporated (if applicable) Is this supplier an Indian Health Facility enrolling with the designated Indian Health Service (IHS) Medicare Administrative Contractor (MAC)? ❑Yes 0 No cons-855B(07111) g SECTION 2: IDENTIFYING INFORMATION (Continued) 2. STATE LICENSE INFORMATiONXERTIFICATION INFORMATION Provide the following information if the supplier has a State license/certification to operate as the supplier type for which you are enrolling. I]State License Not Applicable License Number State Where Issued Effective Date(mmlddlyyyy) Expiration/Renewal Date(mmlddlyyyy) Certification Information 17 Certification Not Applicable Certification Number State Where Issued Effective Date (mmlddlyyyy) Expiration/Renewal Date (mmlddlyyyy) 3. CORRESPONDENCE ADDRESS Provide contact information for the entity or person listed in Question 1 of this section. Once enrolled, the information provided below will be used by the fee-for-service contractor if it needs to contact you directly.This address cannot be a billing agency's address. Mailing Address Line 1 (Street Name and Number) 300 Seminary Avenue Mailing Address Line 2 (Suite, Room, etc.) City/Town state ZIP Code+4 Ukiah California 95482-5400 Telephone Number Fax Number(if applicable) E-mail Address(if applicable) (707)462-7921 (707)462-2938 dhutchison@cityofukiah.com C. Hospitals Only This section should only be completed by hospitals that are currently enrolled or enrolling with a fee-for- service contractor(the Part A Medicare contractor), and will be billing a fee-for-service contractor for Medicare Part B services,as follows: • Hospitals that need departmental billing numbers to bill for Part B practitioner services. • Hospitals requiring a Part B billing number to provide pathology services. • Hospitals requiring a Medicare Part B billing number to provide purchased tests to other Medicare Part B billers. • If the hospital requires more than one departmental Part B billing number, list each department needing a number. If your organization is not a hospital,and bclicves it will need a Part B billing number,contact the designated fee-for-service contractor to determine if this form should be submitted. CMS-855B(07111) 9 SECTION 3: FINAL ADVERSE LEGAL ACTIONS/CONVICTIONS This section captures information on final adverse legal actions, such as convictions,exclusions, revocations, and suspensions. All applicable final adverse legal actions must be reported, regardless of whether any records were expunged or any appeals are pending. Convictions 1. The provider, supplier,or any owner of the provider or supplier was, within the last 10 years preceding enrollment or revalidation of enrollment,convicted of a Federal or State felony offense that CMS has determined to be detrimental to the best interests of the program and its beneficiaries. Offenses include: Felony crimes against persons and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre trial diversions; financial crimes, such as extortion, embezzlement, income tax evasion, insurance fraud and other similar crimes for which the individual was convicted, including guilty pleas and adjudicated pre trial diversions; any felony that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit that results in a conviction of criminal neglect or misconduct); and any felonies that would result in a mandatory exclusion under Section 1128(a) of the Act. 2. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or service under Medicare or a State health care program, or (b) the abuse or neglect of a patient in connection with the delivery of a health care item or service. 3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care item or service. 4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section 1001 .101 or 1001.201. 5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance. Exclusions, Revocations, or Suspensions 1 . Any revocation or suspension of a license to provide health care by any State licensing authority. This includes the surrender of such a license while a formal disciplinary proceeding was pending before a State licensing authority. 2. Any revocation or suspension of accreditation. 3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or State health care program, or any debarment from participation in any Federal Executive Branch procurement or non-procurement program. 4. Any current Medicare payment suspension under any Medicare billing number. 5. Any Medicare revocation of any Medicare billing number. CMS-8558(07111) 12 SECTION 3: FINAL ADVERSE ACTIONS/CONVICTIONS (Continued) FINAL ADVERSE HISTORY 1. Has your organization, under any current or former name or business identity,ever had any of the final adverse actions listed on page 13 of this application imposed against it? ❑YES—Continue Below 0 NO—Skip to Section 4 2. If yes,report each final adverse action, when it occurred, the Federal or State agency or the courts administrative body that imposed the action,and the resolution, if any. Attach a copy of the final adverse action documentation and resolution. FINAL ADVERSE ACTION DATE TAKEN BY RESOLUTION a CMS-855B(07/11) 13 SECTION 4: PRACTICE LOCATION INFORMATION INSTRUCTIONS This section captures information about the physical location(s) where you currently provide health care services. If you operate a mobile facility or portable unit, provide the address for the"Base of Operations," as well as vehicle information and the geographic area serviced by these facilities or units. Only report those practice locations within the jurisdiction of the Medicare fee-for-service contractor to which you will submit this application. If you have practice locations in another Medicare fee-for-service contractor's jurisdiction,complete a separate enrollment application (CMS-855B) for those practice locations and submit it to the Medicare fee-for-service contractor that has jurisdiction over those locations. Provide the specific street address as recorded by the United States Postal Service. Do not provide a P.O. Box. If you provide services in a hospital and/or other health care facility for which you bill Medicare directly for the services rendered at that facility, provide the name and address of the hospital or facility. MOBILE FACILITY AND/OR PORTABLE UNIT A "mobile facility" is generally a mobile home, trailer, or other large vehicle that has been converted, equipped, and licensed to render health care services. These vehicles usually travel to local shopping centers or community centers to see and treat patients inside the vehicle. A "portable unit" is when the supplier transports medical equipment to a fixed location (e.g., physician's office, nursing home) to render services to the patient. The most common types of mobile facilities/portable units are mobile IDTFs, portable X-ray suppliers, portable mammography,and mobile clinics. Physicians and non-physician practitioners (e.g., nurse practitioners, physician assistants) who perform services at multiple locations (e.g.,house calls,assisted living facilities) are not considered to be mobile facilities/portable units. CMS-85SB(07/11) 14 SECTION 4: PRACTICE LOCATION INFORMATION (Continued) A. Practice Location Information If you see patients in more than one practice location,copy and complete Section 4A for each location. To ensure that CMS establishes the correct association between your Medicare legacy number and your NPI, providers and suppliers must list a Medicare legacy number—NPI combination for each practice location. If you have multiple NPIs associated with both a single legacy number and a single practice location, please list below all NPIs and associated legacy numbers for that practice location. If you are changing,adding,or deleting information, check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmiddty)yy) If you are enrolling for the first time, or if you are adding a new practice location,the date you provide should be the date you saw your first Medicare patient at this location. Practice Location Name("Doing Business As"name if different from Legal Business Name) Ukiah Valley Fire Authority Practice Location Street Address Line 1 (Street Name and Number—NQT a P.Q. Box) 1500 South State Street Practice Location Street Address Line 2 (suite, Room, etc.) CitylTown State ZIP Code+4 Ukiah I California 95482-6709 Telephone Number Fax Number(if applicable) E-mail Address(if applicable) 707 462-7921 1(707)462-2938 dhutchison@cityofukiah.com Date you saw your first Medicare patient at this practice location (mmlddlyyyy) 01/01/2020 Medicare Identification Number(if issued) National Provider Identifier 1114560984 Medicare Identification Number (if issued) National Provider identifier Medicare Identification Number(if issued) National Provider Identifier Medicare Identification Number(if issued) National Provider Identifier Medicare Identification Number (if issued) National Provider Identifier Is this practice location a: ❑Group practice office/clinic ❑Skilled Nursing Facility and/or Nursing Facility ❑ Hospital ®Other health care facility ❑Retirementlassisted living community (Specify).Fire/EMS station CILIA Number for this location (if applicable) NIA Attach a copy of the most current CLIA certifications for each of the practice locations reported on this application FDA/Radiology(Mammography) Certification Number for this location (if issued) NIA Attach a copy of the most current FDA certifications for each of the practice locations reported on this application. CMS-8558(07111) 15 SECTION 4: PRACTICE LOCATION INFORMATION (Continued) B. Where do you want remittance notices or special payments sent? If you are changing, adding,or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmlddlyyyy) Medicare will issue payments via electronic funds transfer (EFT). Since payments will be made by EFT, the "Special Payments" address should indicate where all other payment information (e.g., remittance notices, special payments) should be sent. ❑ "Special Payments" address is the same as the practice location (only one address is listed in Section 4A). Skip to Section 4C. ❑x "Special Payments" address is different than that listed in Section 4A, or multiple locations are listed. Provide address below. "Special Payments" Address Line i (PO Box or Street Name and Number) PO Box 3510 "Special Payments" Address Line 2 (Suite, Room, etc.) Citylrown State ZIP Code+4 Silverdale Washington 98383-3510 C. Where do you keep patients' medical records? If you store patients' medical records (current and/or former patients) at a location other than the location in Section 4A or 4E,complete this section with the address of the storage location. Post Office boxes and drop boxes are not acceptable as physical addresses where patients' records are maintained. For IDTFs and mobile facilities/portable units,the patients' medical records must be under the supplier's control.The records must be the supplier's records, not the records of another supplier. If this section is not completed,you are indicating that all records are stored at the practice locations reported in Section 4A or 4E. CMS-855B(07/11) 16 SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS) NOTE: Only report organizations in this section. Individuals must be reported in Section 6. Complete this section with information about all organizations that have 5 percent or more (direct or indirect) ownership interest of,any partnership interest in,and/or managing control of, the supplier identified in Section 2,as well as information on any adverse legal actions that have been imposed against that organization. For examples of organizations that should be reported here,visit our Web site: www.ems.hhs.govlMedicareProviderSupEnroll. If there is more than one organization that should be reported,copy and complete this section for each. MANAGING CONTROL (ORGANIZATIONS) Any organization that exercises operational or managerial control over the supplier,or conducts the day-to-day operations of the supplier, is a managing organization and must be reported.The organization need not have an ownership interest in the supplier in order to qualify as a managing organization. For instance, it could be a management services organization under contract with the supplier to furnish management services for the business. SPECIAL TYPES OF ORGANIZATIONS Governmental/Tribal Organizations If a Federal, State,county,city or other level of government, or an Indian tribe, will be legally and financially responsible for Medicare payments received (including any potential overpayments), the name of that government or Indian tribe should be reported as an owner.The supplier must submit a letter on the letterhead of the responsible government (e.g., government agency) or tribal organization that attests that the government or tribal organization will be legally and financially responsible in the event that there is any outstanding debt owed to CMS.This letter must be signed by an appointed or elected official of the government or tribal organization who has the authority to legally and financially bind the government or tribal organization to the laws, regulations, and program instructions of the Medicare program. Non-Profit, Charitable and Religious Organizations Many non-profit organizations are charitable or religious in nature, and are operated and.or managed by a board of trustees or other governing body. The actual name of the board of trustees or other governing body should be reported in this section. While the organization should be listed in Section 5, individual board members should be listed in Section 6. Each non-profit organization should submit a copy of a 501(c)(3) document verifying its non-profit status. [MS-8558(07111) 21 SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS) (Continued) All organizations that have any of the following must be reported in Section 5: • 5 percent or more ownership of the supplier, • Managing control of the supplier,or • A partnership interest in the supplier, regardless of the percentage of ownership the partner has. Owning/Managing organizations are generally one of the following types: • Corporations (including non-profit corporations) • Partnerships and Limited Partnerships (as indicated above) • Limited Liability Companies • Charitable and/or Religious organizations • Governmental and/or Tribal organizations A. Organization with Ownership Interest and/or Managing Control—Identification Information ❑ Not Applicable If you are changing,adding,or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmlddiyyyy) Check all that apply: ❑5 Percent or More Ownership Interest Cl Partner ®Managing Control Legal Business Name as Reported to the Internal Revenue Service City of Ukiah "Doing Business As" Name(if applicable) Address Line 1 (Street Name and Number) 1500 South State Street Address Line 2 (Suite, Room, etc.) CitylTown State ZIP Code+4 Ukiah California 95482-6709 Telephone Number Fax Number(if applicable) E-mail Address(if applicable) (707)462-7921 (707)462-2938 dhutchison@cityofukiah.com NP1 (if issued) Tax Identification Number(Required) Medicare Identification Number(s) (if issued) 1114560984 94-6000446 What is the effective date this owner acquired ownership of the provider identified in Section 2131 of this application?(ranilddlyyyy) 10/23/2019 What is the effective date this organization acquired managing control of the provider identified in Section 2131 of this application? (innilddlyyyy) NOTE: Furnish both dates if applicable. CM5•8SSB(07l11) 22 SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (ORGANIZATIONS) (Continued) B. Final Adverse Legal Action History If reporting a change to existing information,check "Change," provide the effective date of the change,and complete the appropriate fields in this section. ❑ Change Effective Date: 1. Has this individual in Section 5A above, under any current or former name or business identity, ever had a final adverse legal action listed on page 13 of this application imposed against him/her? ❑YES—Continue Below l]NO—Skip to Section 6 2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the court/administrative body that imposed the action,and the resolution, if any. Attach a copy of the final adverse legal action documentation and resolution. FINAL ADVERSE LEGAL ACTION DATE TAKEN BY RESOLUTION CMS-MB(07111) - 23 CL s L 0 _ Z7 0 L N C C � 0 t m Y w O T N V City of Ukiah Ukiah Valley Fire Authority 1500 South State Street I Ukiah, CA 95482-6709 Phone:(707)462-7921 Fax: (707)462-2938 January 16, 2020 Medicare Part B —CA Provider Enrollment To: Medicare Enrollment We attest that City of Ukiah will be legally and financially responsible in the event that there is an outstanding debt owed to CMS. Sincerely, Sage Sangiacomo City Manager City of Ukiah 12/18ho19 12 :57:46 PM -0500 IRS PAGE 2 OF 2 Department of the Treasury In'reply refer to: 0233325880 Internal Revenue Service Dec 18, 2019 1 71R 147C Ogden, UT 84201 94-6000446 CITY OF UKIAH 300 SEMINARY AVE UKIAH CA 95482-5460 003 Taxpayer Identification Number: 94-6000446 Form(s): Dear Taxpayer: Thank you for your telephone inquiry of December 18th, 2019. Your Employer Identification Number (EIN)is 94-6000446. Please'keep this letter in your permanent records. Enter your name and your EIN on all business federal tax forms and on related correspondence. If you have any questions regarding this letter, please call our Customer Service Department at .1-800-829-0115 between the hours of 7:00 AM and 10:00 PM. If you prefer, you may write to us at the,address shown at the top of the first page of this letter. When you write, please include a telephone number where you may be reached and the best time to call. Sincerely, Ms. Ford '1000727480 Customer Service Representative SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) NOTE: Only Individuals should be reported in Section 6. Organizations must be reported in Section 5. For more information on "direct" and "indirect" owners, go to www.ems.hhs.gov/M`edicareProviderSupEnroll. The supplier MUST have at least ONE owner and/or managing employee. The following individuals must be reported in Section 6A: • All persons who have a 5 percent or greater direct or indirect ownership interest in the supplier; • If(and only if) the supplier is a corporation (whether for-profit or non-profit),all officers and directors of the supplier; • All managing employees of the supplier; • All individuals with a partnership interest in the supplier, regardless of the percentage of ownership the partner has; and • Authorized and delegated officials. Example: A supplier is 100 percent owned by Company C, which itself is 100 percent owned by Individual D. Assume that Company C is reported in Section 5A as an owner of the supplier. Assume further that Individual D, as an indirect owner of the supplier, is reported in Section 6A. Based on this example, the supplier would check the "5 percent or Greater Direct/Indirect Owner" box in Section 6A. NOTE: All partners within a partnership must be reported on this application.This applies to both "General" and "Limited" partnerships. For instance, if a limited partnership has several limited partners and each of them only has a 1 percent interest in the supplier,each limited partner must be reported on this application,even though each owns less than 5 percent.The 5 percent threshold primarily applies to corporations and other organizations that are not partnerships. Non-Profit, Charitable or Religious Organizations: If you are a non-profit charitable or religious organization that has no organizational or individual owners (only board members,directors or managers), you should submit with your application a 501(c)(3) document verifying non-profit status. For purposes of this application, the terms "officer," "director," and "managing employee" are defined as follows: Officer is any person whose position is listed as being that of an officer in the supplier's "articles of incorporation" or "corporate bylaws," or anyone who is appointed by the board of directors as an officer in accordance with the supplier's corporate bylaws. Director is a member of the supplier's "board of directors." It does not necessarily include a person who may have the word "director" in his/her job title (e.g., departmental director,director of operations). Moreover, where a supplier has a governing body that does not use the term "board of directors," the members of that governing body will still be considered "directors."Thus, if the supplier has a governing body titled "board of trustees" (as opposed to "board of directors"),the individual trustees are considered "directors" for Medicare enrollment purposes. Managing Employee means a general manager, business manager, administrator, director,or other individual who exercises operational or managerial control over,or who directly or indirectly conducts,the day-to-day operations of the supplier,either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee of the supplier. NOTE: If a governmental or tribal organization will be legally and financially responsible for Medicare payments received (per the instructions for Governmental/Tribal Organizations in Section 5), the supplier is only required to report its managing employees in Section 6. Owners, partners,officers,and directors do not need to be reported,except those who are listed as authorized or delegated officials on this application. Any information on final adverse actions that have been imposed against the individuals reported in this section must be furnished. If there is more than one individual,copy and complete this section for each individual. Owners,Authorized Officials and/or Delegated Officials must complete this section. CMS-8558(07A1) 24 SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) A. Individuals with Ownership Interest and/or Managing Control--Identification Information If you are changing, adding, or deleting information, check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmlddiyyyy) The name,date of birth,and social security number of each person listed in this Section must coincide with the individual's information as listed with the Social Security Administration. First Name Middle Initial Last Name Jr., Sr., etc. Title Sage Sangiacomo City Manager Date of Birth (mmlddlyyyy) Place of Birth(State) Country of Birth 12/09/1973 California I United States Social Security Number(Required) Medicare Identification Number (if issued) NPI (if issued) 563-37-4337 What is the above individual's relationship with the supplier in Section 2131? (Check all that apply.) ❑5 Percent or Greater Direct/indirect owner ❑Director/Officer ©Authorized Official ❑Contracted Managing Employee ❑ Delegated Official 0 Managing Employee (W-2) ❑Partner What is the effective date this owner acquired ownership of the provider identified in Section 213 1 of this application?(,nnlddlyyyy) What is the effective date this individual acquired managing control of the provider identified in Section 213 1 of this application? (nlfnlddlyyyy) 06/15/2015 NOTE: Furnish both dates if applicable. CMS-8558(07/11) 25 SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) B. Final Adverse Legal Action History Complete this section for the individual reported in Section 6A above. If reporting a change to existing information,check "change," provide the effective date of the change and complete the appropriate fields in this section. ❑ Change Effective Date: i. Has this individual in Section 6A above, under any current or former name or business identity,ever had a final adverse legal action listed on page 13 of this application imposed against him/her? ❑YES—Continue Below ® NO—Skip to Section 8 2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the court/administrative body that imposed the action, and the resolution, if any. Attach a copy of the final adverse legal action documentation and resolution. FINAL ADVERSE LEGAL ACTION DATE TAKEN BY RESOLUTION CMS-855B(07111) 26 SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) A. Individuals with Ownership Interest and/or Managing Control---Identification Information If you are changing, adding, or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mm/ddlyyyy) The name,date of birth,and social security number of each person listed in this Section must coincide with the individual's information as listed with the Social Security Administration. First Name Middle Initial Last Name Jr., Sr., etc. Title Douglas Hutchison Fire Chief Date of Birth (mmlddlyyyy) Place of Birth(State) Country of Birth 03/07/1968 Oregon United States Social Security Number(Required) Medicare Identification Number (if issued) NPI (if issued) 543-76-6734 What is the above individual's relationship with the supplier in Section 2131? (Check all that apply.) ❑5 Percent or Greater Direct/indirect Owner x❑Director/Officer ❑Authorized Official ❑Contracted Managing Employee 0 Delegated Official 0 Managing Employee (W-2) ❑ Partner What is the effective date this owner acquired ownership of the provider identified in Section 2131 of this application?(in„ilddlyyyy) What is the effective date this individual acquired managing control of the provider identified in Section 213 1 of this application? (mmIddlyyyy) 02/19/2019 NOTE: Furnish both dates if applicable. CMS•8558(07/11) 25 SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) B. Final Adverse Legal Action History Complete this section for the individual reported in Section 6A above. If reporting a change to existing information,check "change," provide the effective date of the change and complete the appropriate fields in this section. ❑ Change Effective Date: 1. Has this individual in Section 6A above, under any current or former name or business identity,ever had a final adverse legal action listed on page 13 of this application imposed against him/her? ❑YES—Continue Below ®NO—Skip to Section S 2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the court/administrative body that imposed the action,and the resolution, if any. Attach a copy of the final adverse legal action documentation and resolution. FINAL ADVERSE LEGAL ACTION DATE TAKEN BY RESOLUTION CMS•855B(07111) 26 SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) A. Individuals with Ownership Interest and/or Managing Control—Identification Information If you are changing, adding, or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmlddlyyyy) The name,date of birth,and social security number of each person listed in this Section must coincide with the individual's information as listed with the Social Security Administration. First Name Middle Initial Last Name Jr., Sr., etc. Title Stephanie Abba Administrative Assistant Date of Birth (mmlddlyyyy) Place of Birth (State) Country of Birth 11/02/1962 California United States Social Security Number(Required) Medicare Identification Number(if issued) NPI (if issued) 588-13-5464 What is the above individual's relationship with the supplier in Section 2131? (Check all that apply.) ❑5 Percent or Greater Directlindirect Owner D Director/Officer ❑Authorized Official ❑Contracted Managing Employee ❑x Delegated Official ❑x Managing Employee (W-2) ❑ Partner What is the effective date this owner acquired ownership of the provider identified in Section 213 1 of this application?(ninilddlyyyy) What is the effective date this individual acquired managing control of the provider identified in Section 2B1 of this application?(mm/ddlyy)y) 04/03/2017 NOTE: Furnish both dates if applicable. CMS-85SB(07/11) 25 SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION (INDIVIDUALS) (Continued) B. Final Adverse Legal Action History Complete this section for the individual reported in Section 6A above. If reporting a change to existing information,check "change," provide the effective date of the change and complete the appropriate fields in this section. ❑ Change Effective Date: 1. Has this individual in Section 6A above, under any current or former name or business identity,ever had a final adverse legal action listed on page 13 of this application imposed against himlher? ❑YES—Continue Below © NO—Skip to Section 8 2. If YES, report each final adverse legal action, when it occurred, the Federal or State agency or the court/administrative body that imposed the action, and the resolution, if any. Attach a copy of the final adverse legal action documentation and resolution. FINAL ADVERSE LEGAL ACTION DATE TAKEN BY RESOLUTION CMS•8559(07/11) 26 SECTION 7: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 8: BILLING AGENCY INFORMATION A billing agency is a company or individual that you contract with to prepare and submit your claims. If you use a billing agency,you are responsible for the claims submitted on your behalf. ❑Check here if this section does not apply and skip to Section 13. BILLING AGENCY NAME AND ADDRESS If you are changing, adding, or deleting information, check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmiddlym) Legal Business/Individual Name as Reported to the Social Security If Individual, Billing Agent Date of Birth Administration or the Internal Revenue Service (mmlddlyyyy) Systems Design West LLC "Doing Business As" Name (if applicable) Tax identification/Social Security Number (required) 46-3687768 Billing Agency Street Address Line 1 (Street Name and Number) 19265 Powder Hill PI NE Billing Agency Street Address Lime Z (Suite, Room, etc.) Citylrown State ZIP Code+4 Poulsbo Washington 98370-7455 Telephone Number Fax Number(if applicable) E-mail Address(if applicable) (360)394-7020 (360)394-7099 ShelleyB@sdwems.com SECTION 9: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 10: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 11: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) SECTION 12: FOR FUTURE USE (THIS SECTION NOT APPLICABLE) CM5-6558(07111) 27 Department of the Treasury In reply refer to: 0458648819 Internal Revenue Service Oct 16, 2015 LTR 147C Ogden, UT 84201 46-3687768 SYSTEMS DESIGN WEST LLC JENNIFER BRADS SOLE MBR 19265 POWDER HILL PL NE POULSBO WA 98370-7455 651 Taxpayer Identification Number: 46.3687768 Form(s): Dear Taxpayer: Thank you for your telephone inquiry of October 16th, 2015. Your Employer Identification Number(EIN)is 46-3687768. Please keep this letter in your permanent records. Enter your name and your EIN on all business federal tax forms and on related correspondence. If you have any questions regarding this letter, please call our Customer Service Department at 1-800-829-0115 between the hours of 7:00 AM and 7:00 PM. If you prefer, you may write to us at the address shown at the top of the first page of this letter. When you write, please include a telephone number where you may be reached and the best time to call. Sincerely, Ms. Harness 1000247437 Customer Service Representative SECTION 13: CONTACT PERSON If questions arise during the processing of this application, the fee-for-service contractor will contact the individual shown below. If the contact person is either an authorized or delegated official, check the appropriate box below. •Contact an Authorized Official listed in Section 15. ❑Contact a Delegated Official listed in Section 16. First Name Middle Initial 1 Last Name Jr.,Sr., etc. Kelsey Ross Telephone Number Fax Number(if applicable) E-mail Address(if applicable) (360) 394-7020 (360) 394-7099 KelseyR@SDWems.com Address Line 1 (Street Name and Number) PO Box 3510 Address Line 2 (Suite, Room, etc.) CitylTown State ZIP Code+4 Silverdale Washington 98383-3510 SECTION 14: PENALTIES FOR FALSIFYING INFORMATION This section explains the penalties for deliberately falsifying information in this application to gain or maintain enrollment in the Medicare program. I- 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false,fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false,fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute. 2. Section l I2813(a)(1) of the Social Security Act authorizes criminal penalties against any individual who, "knowingly and willfully," makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program. The offender is subject to fines of up to $25,000 andior imprisonment for up to five years. 3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part,on any person who: a) knowingly presents,or causes to be presented,to an officer or any employee of the United States Government a false or fraudulent claim for payment or approval; b) knowingly makes, uses,or causes to be made or used,a false record or statement to get a false or fraudulent claim paid or approved by the Government; or c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid. The Act imposes a civil penalty of$5,000 to $10,000 per violation, plus three times the amount of damages sustained by the Government. CMS-855B(07111) 28 SECTION 13: CONTACT PERSON If questions arise during the processing of this application,the fee-for-service contractor will contact the individual shown below. If the contact person is either an authorized or delegated official, check the appropriate box below. ❑Contact an Authorized Official listed in Section 15. ❑Contact a Delegated Official listed in Section 16. First Name Middle Initial Last Name Jr.,Sr., etc. Shelley L Brewington Telephone Number Fax Number(if applicable) E-mail Address(if applicable) (360) 394-7020 (360) 394-7099 ShelieyB@sdwems.com Address Line 1 (Street Name and Number) PO Box 3510 Address Line 2 (Suite, Room, etc.) City/Town State ZIP Code+4 Silverdale Washington 98383-3510 SECTION 14; PENALTIES FOR FALSIFYING INFORMATION This section explains the penalties for deliberately falsifying information in this application to gain or maintain enrollment in the Medicare program. I. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact,or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false,fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five year%. Offenders that are organizations are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing statute. 2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual who, "knowingly and willfully," makes or causes to be made any false statement or representation of a material fact in any application for any benefit or payment under a Federal health care program. The offender is subject to fines of up to $25,000 and;`or imprisonment for up to five years. 3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who: a) knowingly presents, or causes to be presented, to an officer or any employee of the United States Government a false or fraudulent claim for payment or approval; b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government; or c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid. The Act imposes a civil penalty of$5,000 to $10,000 per violation, plus three times the amount of damages sustained by the Government. CMS•8556(07111) 28 SECTION 14: PENALTIES FOR FALSIFYING INFORMATION (Continued) 4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (includ- ing an organization, agency or other entity) that knowingly presents or causes to be presented to an officer, employee, or agent of the United States,or of any department or agency thereof, or of any State agency...a claim...that the Secretary determines is for a medical or other item or service that the person knows or should know: a) was not provided as claimed; and/or b) the claim is false or fraudulent. This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment of up to three times the amount claimed, and exclusion from participation in the Medicare program and State health care programs. 5_ 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme,or device a material fact; or makes any materially false, fictitious,or fraudulent statements or representations, or makes or uses any materially false fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits, items or services.The indi- vidual shall be fined or imprisoned up to 5 years or both. 6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute, or attempt, to executive a scheme or artifice to defraud any health care benefit program,or to obtain, by means of false or fraudulent pretenses, representations,or promises, any of the money or property owned by or under the control of any, health care benefit program in connection with the delivery of or payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up to 10 years or both. If the violation results in serious bodily injury, an individual will be fined or imprisoned up to 20 years,or both. If the violation results in death, the individual shall be fined or imprisoned for any term of years or for life, or both. 7. The government may assert common law claims such as "common law fraud,""money paid by mistake," and "unjust enrichment." Remedies include compensatory and punitive damages, restitution,and recovery of the amount of the unjust profit. CMS-8558(07/11) 29 SECTION 14: PENALTIES FOR FALSIFYING INFORMATION (Continued) 4. Section 1128A(a)(1) of the Social Security Act imposes civiI liability, in part,on any person (includ- ing an organization, agency or other entity) that knowingly presents or causes to be presented to an officer, employee, or agent of the United States,or of any department or agency thereof, or of any State agency...a claim...that the Secretary determines is for a medical or other item or service that the person knows or should know: a) was not provided as claimed; and/or b) the claim is false or fraudulent. This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment of up to three times the amount claimed, and exclusion from participation in the Medicare program and State health care programs. 5. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme,or device a material fact; or makes any materially false, fictitious, or fraudulent statements or representations, or makes or uses any materially false fictitious, or fraudulent statement or entry, in connection with the delivery of or payment for health care benefits, items or services.The indi- vidual shall be fined or imprisoned up to 5 years or both. 6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute, or attempt,to executive a scheme or artifice to defraud any health care benefit program, or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by or under the control of any, health care benefit program in connection with the delivery of or payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up to 10 years or both. If the violation results in serious bodily injury, an individual will be fined or imprisoned up to 20 years, or both. If the violation results in death, the individual shall be fined or imprisoned for any term of years or for life, or both. 7. The government may assert common law claims such as "common law fraud,""money paid by mistake," and "unjust enrichment." Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the unjust profit. CMS-8558(07/11) 29 SECTION 15: CERTIFICATION STATEMENT An AUTHORIZED OFFICIAL means an appointed official (for example,chief executive officer,chief financial officer, general partner, chairman of the board,or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organization's status in the Medicare program, and to commit the organization to fully abide by the statutes, regulations,and program instructions of the Medicare program. A DELEGATED OFFICIAL means an individual who is delegated by an authorized official the authority to report changes and updates to the supplier's enrollment record. A delegated official must be an individual with an "ownership or control interest" in (as that term is defined in Section I I24(a)(3) of the Social Security Act),or be a W-2 managing employee of,the supplier. Delegated officials may not delegate their authority to any other individual. Only an authorized official may delegate the authority to make changes and/or updates to the supplier's Medicare status. Even when delegated officials are reported in this application,an authorized official retains the authority to make any such changes and/or updates by providing his or her printed name, signature,and date of signature as required in Section 15B. NOTE. Authorized officials and delegated officials must be reported in Section 6,either on this application or on a previous application to this same Medicare fee-for-service contractor. If this is the first time an authorized and/or delegated official has been reported on the CMS-855B,you must complete Section 6 for that individual. By his/her signature(s),an authorized official binds the supplier to all of the requirements listed in the Certification Statement and acknowledges that the supplier may be denied entry to or revoked from the Medicare program if any requirements are not met. All signatures must be original and in ink. Faxed, photocopied, or stamped signatures will not be accepted. Only an authorized official has the authority to sign (1) the initial enrollment application on behalf of the supplier or (2) the enrollment application that must be submitted as part of the periodic revalidation process. A delegated official does not have this authority. By signing this application,an authorized official agrees to immediately notify the Medicare fee-for-service contractor if any information furnished on the application is not true,correct,or complete. In addition, an authorized official, by his/her signature,agrees to notify the Medicare fee-for-service contractor of any future changes to the information contained in this form,after the supplier is enrolled in Medicare, in accordance with the timeframes established in 42 C.F.R. 424.520(b). (IDTF changes of information must be reported in accordance with 42 C.F.R.410.33.) The supplier can have as many authorized officials as it wants. If the supplier has more than two authorized officials, it should copy and complete this section as needed. EACH AUTHORIZED AND DELEGATED OFFICIAL MUST HAVE AND DISCLOSE HIS/HER SOCIAL SECURITY NUMBER. CMS-8558(07111) 30 SECTION 15: CERTIFICATION STATEMENT (Continued) A. Additional Requirements for Medicare Enrollment These are additional requirements that the supplier must meet and maintain in order to bill the Medicare program. Read these requirements carefully. By signing,the supplier is attesting to having read the requirements and understanding them. By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in Section 16 agree to adhere to the following requirements stated in this Certification Statement: 1. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the Medicare contractor of any future changes to the information contained in this application in accordance with the timeframes established in 42 C.F.R. § 424.516. 1 understand that any change in the business structure of this supplier may require the submission of a new application. 2. 1 have read and understand the Penalties for Falsifying Information, as printed in this application. I understand that any deliberate omission, misrepresentation, or falsification of any information contained in this application or contained in any communication supplying information to Medicare, or any deliberate alteration of any text on this application form, may be punished by criminal, civil, or administrative penalties including, but not limited to, the denial or revocation of Medicare billing privileges, and/or the imposition of fines, civil damages, and/or imprisonment. 3. I agree to abide by the Medicare laws, regulations and program instructions that apply to this supplier.The Medicare laws, regulations, and program instructions are available through the Medicare contractor. I understand that payment of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law),and on the supplier's compliance with all applicable conditions of participation in Medicare. 4. Neither this supplier, nor any five percent or greater owner, partner, officer,director, managing employee, authorized official, or delegated official thereof is currently sanctioned, suspended, debarred, or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or any other Federal program, or is otherwise prohibited from supplying services to Medicare or other Federal program beneficiaries. 5. 1 agree that any existing or future overpayment made to the supplier by the Medicare program may be recouped by Medicare through the withholding of future payments. 6. 1 will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare, and I will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity. 7. 1 authorize any national accrediting body whose standards are recognized by the Secretary as meeting the Medicare program participation requirements, to release to any authorized representative, employee, or agent of the Centers for Medicare & Medicaid Services (CMS) a copy of my most recent accreditation survey, together with any information related to the survey that CMS may require (including corrective action plans). CMS-8558(07/11) 31 SECTION 15: CERTIFICATION STATEMENT (Continued) B. 1ST Authorized Official Signature I have read the contents of this application. My signature legally and financially binds this supplier to the laws, regulations,and program instructions of the Medicare program. By my signature, I certify that the information contained herein is true, correct, and complete and I authorize the Medicare fee-for-service contractor to verify this information. If I become aware that any information in this application is not true, correct,or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance with the time frames established in 42 CFR § 424.516. If you are changing,adding, or deleting information, check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmlddlyyyy) Authorized Official's Information and Signature First Name Middle Last Name Suffix(e.g.,Jr., Sr.) Initial Sage Sangiacomo Telephone Number Title/Position (707)462-7921 City Manager Authorized Official Signature (First Middle, Last Name,Jr., Sr., M.D., D.O., etc.) Date Signed (mmlddlyyyy) c Do C1 q (blue ink eferred) C. 2ND Authorized Official Signature I have read the contents of this application. My signature legally and financially binds this supplier to the laws, regulations,and program instructions of the Medicare program. By my signature, I certify that the information contained herein is true,correct,and complete and I authorize the Medicare fee-for-service contractor to verify this information. If I become aware that any information in this application is not true, correct,or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance with the time frames established in 42 CFR § 424.516. If you are changing, adding, or deleting information,check the applicable box, furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmldd/yyyy) Authorized Official's Information and Signature First Name Middle Initial Last Name Suffix(e.g.,Jr., Sr.) Telephone Number Title/Position Authorized Official Signature (first Middle, Last Name,Jr., Sr., M.D., D.O., etc.) Date Signed (mmlddlyyyy) All signatures must be original and signed in ink(blue ink preferred).Applications with signatures deemed not original will not be processed.Stamped,faxed or copied signatures will not be accepted. CMS-8558(07111) j SECTION 15: CERTIFICATION STATEMENT (Continued) B. 1ST Authorized Official Signature I have read the contents of this application. My signature legally and financially binds this supplier to the laws, regulations,and program instructions of the Medicare program. By my signature, I certify that the information contained herein is true, correct,and complete and I authorize the Medicare fee-for-service contractor to verify this information. If I become aware that any information in this application is not true, correct,or complete, I agree to notify the Medicare fee-for-service contractor of this fact in accordance with the time frames established in 42 CFR § 424.516. If you are changing, adding,or deleting information,check the applicat ' and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD DATE (mmiddiyyyy) Authorized Official's Information ar First Name Middle Last Name Initial Sage Sangiacomo Telephone Number Title/Position (707)462-7921 City Manager Authorized Official Signature (First, Middle, Last Name,Jr., Sr., M.D., D.O., etc.) Date Signed (mmlddlyyyy) a- ao - QPa0 (blue ink p eferred) C. 2NO Authorized Official Signature I have read the contents of this application. My signature legally and financially binds this supplier to the laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the information contained herein is true, correct,and complete and I authorize the Medicare fee-for-service contractor to verify this information. If I become aware that any information in this application is not true, correct,or complete, I agree to notify the Medicare fee-for.service contractor of this fact in accordance with the time frames established in 42 CFR § 424.516. If you are changing, adding, or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmldwym) Authorized Official's Information and Signature First Name' Middle initial Last Name I Suffix(e.g., Jr., Sr.) Telephone Number I Title/Position Authorized Official Signature (First, Middle, Last Name,Jr., Sr., M.D., D.O., etc.) Date Signed (mmlddlyyyy) All signatures must be original and signed in ink(blue ink preferred).Applications with signatures deemed not original will not be processed. Stamped,faxed or copied signatures will not be accepted. CMS 855E(07/11) 32 SECTION 16: DELEGATED OFFICIAL (OPTIONAL) • You are not required to have a delegated official. However, if no delegated official is assigned, the authorized official(s) will be the only person(s) who can make changes and/or updates to the supplier's status in the Medicare program. • The signature of a delegated official shall have the same force and effect as that of an authorized official, and shall legally and financially bind the supplier to the laws, regulations, and program instructions of the Medicare program. By his or her signature, the delegated official certifies that he or she has read the Certification Statement in Section 15 and agrees to adhere to all of the stated requirements. A delegated official also certifies that he/she meets the definition of a delegated official. When making changes and/or updates to the supplier's enrollment information maintained by the Medicare program,a delegated official certifies that the information provided is true,correct,and complete. • Delegated officials being deleted do not have to sign or date this application. • Independent contractors are not considered "employed" by the supplier,and therefore cannot be delegated officials. • The signature(s) of an authorized official in Section 16 constitutes a legal delegation of authority to all delegated official(s) assigned in Section 16. • If there are more than two individuals,copy and complete this section for each individual. A. 1ST Delegated Official Signature If you are changing,adding,or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑DELETE DATE (mmlddlyyyy) Delegated Official First Name Middle Initial Last Name Suffix(e.g.,Jr., Sr.) Douglas Hutchison Delegated Official Signature (Firs die, Last Name, Jr., Sr., M.D., A.O., etc.) Date Signed (mmlddlyyyy) 6 Z /y Zdzo Telephone Number I@ Check here if Delegated Official is a W-2 Employee (707)462-7921 Authorized Official's Signature Assigning this Delegation (First, Middle, Last Name,Jr., Sr., Date Signed (mmlddlyyyy) M.D., D.O., etc.) -5/ 1 - -a-3 Q0 (blue ink pre erred) CMS-8558(07111) 33 SECTION 16: DELEGATED OFFICIAL (OPTIONAL) B. 2ND Delegated Official Signature If you are changing, adding,or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmiddlyyyy) Delegated Official First Name Middle Initial Last Name Suffix(e.g.,Jr.,Sr.) Stephanie Abba Delegated Official Signature (First Middle, Last Name,Jr., Sr., M.D., D.O., etc.) Date Signed (mmlddlyyyy) Telephone Number ❑x Check here if Delegated Official is a W-2 Employee 707-462-7921 Authorized Official's Signature Assigning this Delegation (First Middle, Last Name,Jr., Sr., Date Signed (mmlddlyyyy) M.D., D.O., etc.) 4 ae, (blue ink pre rred) All signatures must be original and signed in ink(blue ink preferred).Applications with signatures deemed not original will not be processed. Stamped,faxed or copied signatures will not be accepted. CMS-855B(07111) 34 SECTION 17: SUPPORTING DOCUMENTS This section lists the documents that, if applicable,must be submitted with this enrollment application. If you are newly enrolling,or are reactivating or revalidating your enrollment,you must provide all applicable documents. For changes,only submit documents that are applicable to that change. The fee-for-service contractor may request,at any time during the enrollment process, documentation to support or validate information reported on the application. The Medicare fee-for- service contractor may also request documents from you,other than those identified in this Section 117,as are necessary to bill Medicare. MANDATORY FOR ALL PROVIDER/SUPPLIER TYPES 0 Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name (e.g., IRS form CP 575) provided in Section 2. (NOTE: This information is needed if the applicant is enrolling their professional corporation, professional association,or limited liability corporation with this application or enrolling as a sole proprietor using an Employer Identification Number.)" ❑x Completed Form CMS 588,for Electronic Funds Transfer Authorization Agreement. (NOTE: If a supplier already receives payments electronically and is not making a change to its banking information,the CMS-588 is not required.) MANDATORY FOR SELECTED PROVIDER/SUPPLIER TYPES ❑ Copy(s) of all documentation verifying IDTF Supervisory Physician(s) proficiency and/or State licenses or certification for IDTF non physician personnel. ❑ Copy(s) of all documentation verifying the State licenses or certifications of the laboratory Director or non-physician practitioner personnel of an independent clinical laboratory. MANDATORY, IF APPLICABLE ❑ Copy of IRS Determination Letter, if supplier is registered with the IRS as non-profit. ❑ Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity. (e.g., Form 8832). (NOTE: A disregarded entity is an eligible entity that is treated as an entity not separate from its single owner for income tax purposes. ❑ Statement in writing from the bank. If Medicare payment due a supplier of services is being sent to a bank (or similar financial institution) with whom the supplier has a lending relationship (that is, any type of loan), then the supplier must provide a statement in writing from the bank (which must be in the loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables. ❑ Copy(s) of all final adverse action documentation (e.g., notifications, resolutions,and reinstatement letters). ❑ Completed Form(s) CMS 855R, Reassignment of Medicare Benefits. ❑ Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement. ❑ Copy of an attestation for government entities and tribal organizations. ❑ Copy of FAA 135 certificate (air ambulance suppliers). ❑ Copy(s) of comprehensive liability insurance policy (IDTFs only). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938- 0685.The time required to complete this information collection is estimated to 6 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard,Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing. CLAYS-855B(07/11) 35 ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS All ambulance service suppliers enrolling in the Medicare program must complete this attachment. A. Geographic Area This section is to be completed with information about the geographic area in which this company provides ambulance services. If you are changing, adding,or deleting information,check the applicable box,furnish the effective date,and complete the appropriate fields in this section. Provide the city/town, State, and ZIP code for all locations where this ambulance company renders services. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmlddlyyyy) NOTE: If the ambulance company has vehicles garaged within a different Medicare contractor's jurisdiction,a separate CMS-855B enrollment application must be submitted to that fee-for-service contractor. 1. INITIAL REPORTING AND/OR ADDITIONS If services are provided in selected cities/towns, provide the locations below. List ZIP codes only if they are not within the entire city/town. CITY/TOWN STATE ZIP CODE Ukiah California Z. DELETIONS If services are no longer provided in selected cities/towns, provide the locations below. List ZIP codes only if they are not within the entire city/town. CITY/TOWN STATE ZIP CODE CMS-855B(07111) 36 ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS (Continued) B. State License Information If you are changing,adding,or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. Crew members must complete continuing education requirements in accordance with State and local licensing laws. Evidence of re-certification must be retained with the employer in case it is required by the Medicare fee-for-service contractor. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmiddlyyyy) Is this ambulance company licensed in the State where services are rendered and billed for? ❑YES Rl NO If NO, explain why: Per Mendocino County ordinance,City of Ukiah does not need a permit to provide ambulance service since we are a public agency. If YES, provide the license information for the State where this ambulance service supplier will be rendering services and billing Medicare. Attach a copy of the current State license. License Number Issuing State (if applicable) Issuing City/Town (if applicable) NIA Effective Date(mmlddlyyyy) Expiration Date (mmlddly)ry) C. Paramedic Intercept Services Information Paramedic Intercept Services involve an arrangement between a Basic Life Support (BLS) ambulance company and an Advanced Life Support (ALS) ambulance company whereby the latter provides the ALS services and the BLS ambulance company provides the transportation component. If such an arrangement exists between the enrolling ambulance company and another ambulance company, the enrolling ambulance company must attach a copy of the signed contract. For more information, see 42 C.F.R. 410.40. If reporting a change to information about a previously reported agreement/contract,check "Change" and provide the effective date of the change. ❑ Change Effective Date: Does this ambulance company currently participate in a paramedic intercept services arrangement? ❑YES ONO CMS-855B(07/11) 37 ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS (Continued) D. Vehicle Information Complete this section with information about the vehicles used by this ambulance company and the services they provide. If there is more than one vehicle,copy and complete this section as needed. Attach a copy of each vehicle registration. To qualify as an air ambulance supplier, the following is required: • A written statement, signed by the President,Chief Executive Officer or Chief Operating Officer of the airport from where the aircraft is hangared that gives the name and address of the facility,and • Proof that the enrolling ambulance company,or the company leasing the air ambulance vehicle to the enrolling ambulance company, possesses a valid charter flight license (FAA 135 Certificate) for the aircraft being used as an air ambulance. if the enrolling ambulance company owns the aircraft, the owner's name on the FAA 135 Certificate must be the same as the enrolling ambulance company's name (or the ambulance company owner as reported in Sections 5 or 6) in this application. If the enrolling ambulance company leases the aircraft from another company, a copy of the lease agreement must accompany this enrollment application. If you are changing,adding,or deleting information,check the applicable box,furnish the effective date, and complete the appropriate fields in this section. CHECK ONE ❑CHANGE ❑ADD ❑ DELETE DATE (mmiddly)") Type(automobile, aircraft, boat, etc.) Vehicle Identification Number Automobile 1 FDWE35F2YHB32311 Make (e.g., Ford) Model (e.g.,350T) Year(yyyy) Ford Ambulance 2000 Does this vehicle provide: Advanced life support (Level 1) BYES ❑ NO Specialty care transport BYES ❑ NO Advanced life support (Level 2) BYES ❑ NO Land ambulance 0 YES ❑ NO Basic life support BYES ❑ NO Air ambulance-fixed wing ❑YES 17 NO Emergency runs 0 YES ❑ NO Air ambulance-rotary wing ❑YES El NO Non-emergency runs 0 YES ❑ NO Marine ambulance ❑YES CI NO CMS•855B(07111) 38 d'- rr I eb C raru ru 0 rn o W i . ru U& N ru ¢ y w _ C P W �- Q o z "� o d LL a$ xklj L U. C '- N ru 6 Q LU c a a tiE XA E = W t� G i' mE3 m Gw cc itui Li J�ca A ui c r� V � g c ' rua ru rn g � X M1 X J O w m W H W = m A W W YEA 2 �u � O 16 � g 1 � E �A may o� n u A a Vm 3 � Form Approved OM8 DEPARTMENT OF HEALTH AND HUMAN SERVICES No.0938-0626 Expires:Ol/2020 CENTERS FOR MEDICARE S MEDICAID SERVICES ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION AGREEMENT PART I: REASON FOR SUBMISSION Reason for Submission: © New EFT Enrollment ❑ Check here if EFT payment is being made to Individual O Group the Home Office of the Chain Organization ❑ Change to Current EFT Enrollment (Attach letter Authorizing EFT payment to (e.g.account or bank changes) Chain Home Office) ❑ Cancel EFT Enrollment Since your last EFT authorization agreement submission, have you had a: ❑ Change of Ownership, and/or ❑ Change of Practice Location? If you checked either a change of ownership or change of practice location above, you must submit a change of information (using the Medicare enrollment application)to the Medicare contractor that services your geographical area(s) prior to or accompanying this EFT authorization agreement submission. PART II: ACCOUNT HOLDER INFORMATION Provider/SupplierAndirect Payment Procedure(IPP)Biller Legal Business Name City of Ukiah Chain Organization Name or Home Office Legal Business Name(if different from Chain Organization Name) Account Holder's Street Address 1500 South State Street Account Holder's City Account Holder's State Account Holder's Zip Code Ukiah California_ 95482-6709 Tax Identification Number(TIN) Designate TIN 0®© 0❑®0®®©❑❑❑ O SSN (enrolling as an individual)OR ® EIN (enrolling as a group/organizationlcorporation Medicare Identification Number(if issued) Health Plan Identifier(HPID)or Other Entity Identifier(OEID)(IPP Entities Only) ❑❑❑❑❑❑❑❑❑❑❑❑ 11:10000110000 National Provider Identifier(NPI) National Provider Identifier(NPI) National Provider Identifier(NPI) ❑1 00®0© 0❑0®® ❑❑❑❑❑❑❑❑❑❑ ❑❑❑❑❑❑❑❑❑❑ PART III: FINANCIAL INSTITUTION INFORMATION Financial Institution's Name Umpqua Sank Financial Institution's Street Address 607 S State Street Financial Institution's City/Town Financial Institution's State/Province Financial Institution's Zip Postal Code Ukiah Califomia 195482 Financial Institution's Telephone Number Financial Institution's Contact Person(optional) (707)467-2241 Shauna Rotbergs Financial Institution Routing Number(must be 9 digits) ❑1 ❑2 ❑3M2 9 ElEEl5 ® Provider's/Supplier's/IPP Entity's Account Number with Financial Institution(include all zeroes) Type of Account(check one) DM©10®©M M❑❑❑❑❑❑❑❑❑ ®Checking Account O Savings Account Please include a confirmation of account information on bank letterhead or a voided check.When submitting the documentation, it should contain the name on the account, electronic routing transit number, account number and type. If submitting bank letterhead,the bank officer's name and signature is also required.This information will be used to verify your account number. NOTE:Starter checks are not acceptable for EFT confirmations. PLEASE NOTE:In accordance with section 1104 of the Affordable Care Act, enrollment of electronic fund transfer(EFT) is for electronic fund transfer authorization only. EFT enrollment does not constitute enrollment as a provider or supplier in the Medicare program. Form CMS-588(01117) t PART IV: CONTACT PERSON This is the person we will contact for any questions regarding this EFT. Contact Person's Name Contact Person's Title Kelsey Ross Enrollments Manager Contact Person's Telephone Number Contact Person's E-mail Address (360)394-7052 KelseyR@SDWems.com PART V: AUTHORIZATION I hereby authorize the Centers for Medicare & Medicaid Services (CMS)to initiate credit entries, and in accordance with 31 CFR part 210.6(f) initiate adjustments for any duplicate or erroneous entries made in error to the account indicated above. I hereby authorize the financial institution/bank named above to credit and/or debit the same to such account. CMS may assign its rights and obligations under this agreement to CMS' designated fee-for-service contractor. CMS may change its designated contractor at CMS' discretion. If payment is being made to an account controlled by a Chain Home Office, the Provider of Services hereby acknowledges that payment to the Chain Office under these circumstances is still considered payment to the Provider, and the Provider authorizes the forwarding of Medicare payments to the Chain Home Office. If the account is drawn in the Physician's or Individual Practitioner's Name, or the Legal Business Name of the Provider/Supplier or IPP entity, the said Provider/Supplier or IPP entity certifies that he/she has sole control of the account referenced above, and certifies that all arrangements between the Financial Institution and the said Provider/Supplier or IPP entity are in accordance with all applicable Medicare regulations and instructions. This authorization agreement is effective as of the signature date below and is to remain in full force and effect until CMS has received written notification from me of its termination in such time and such manner as to afford CMS and the Financial Institution a reasonable opportunity to act on it. CMS will continue to send the direct deposit to the Financial Institution indicated above until notified by me that I wish to change the Financial Institution receiving the direct deposit. If my Financial Institution information changes, l agree to submit to CMS an updated EFT Authorization Agreement. SIGNATURE LINE Authorized/Delegated Official Name(Print) Authorized/Delegated Official Telephone Number Sage Sangiacomo 707-462-7921 Authorized/Delegated Official Title Authorized/Delegated Official E-mail Address City Manager ssangiacomo@cityofukiah.com Authorized/Delegated fficial Signature(Note:Must be original signature in black or blue ink.) Date '-)' a•76 0�' PRIVAC ACT 46VISORY STATEMENT Sections 1842, 1862(b) and 1874 of title XVIII of the Social Security Act authorize the collection of this information. The purpose of collecting this information is to authorize electronic funds transfers. Per 42 CFR 424.510(e)(1), providers and suppliers are required to receive electronic funds transfer (EFT) at the time of enrollment, revalidation, change of Medicare contractors or submission of an enrollment change request; and (2) submit the CMS-588 form to receive Medicare payment via electronic funds transfer. The information collected will be entered into system No. 09-70-0501, titled "Carrier Medicare Claims Records," and No. 09-70-0503, titled "Intermediary Medicare Claims Records" published in the Federal Register Privacy Act Issuances, 1991 Comp. Vol. 1, pages 419 and 424, or as updated and republished. Disclosures of information from this system can be found in this notice. You should be aware that P.L. 100-503,the Computer Matching and Privacy Protection Act of 1988, permits the government, under certain circumstances, to verify the information you provide by way of computer matches. According to the Paperwork Reduction Act of 1995,no persons are required to respond to a collection of information unless it displays a valid OMB control number.The valid OMB control number for this information collection is 0938-0626.The time required to complete this information collection is estimated to average 30 minutes per response,including the time to review instructions,search existing data resources,gather the data needed,and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s)or suggestions for improving this form,please write to:CMS,Attn: PRA Reports Clearance Officer,7500 Security Boulevard,Baltimore,Maryland 21244-1850. DO NOT MAIL THIS FORM TO THIS ADDRESS. MAILING YOUR APPLICATION TO THIS ADDRESS WILL SIGNIFICANTLY DELAY PROCESSING. Form CMS-588(01/17) 2