What Information is Required on CMS-L564?

When filling out Form CMS-L564, there are 19 sections related to who an entity has non physician owners or partners, who own the group practice you work for, and who has contractual arrangements with physicians.

What is the Deadline for Submitting CMS-L54?

Physicians have 30 days from their start date to submit Form CMS-L564 to either a MAC or carrier. The 30 day period begins on whatever day an entity has non physician owners or partners, owns the group practice you work for, has contractual arrangements (buying/selling arrangements) with physicians.

What are the Penalties for Failing to Submit Form CMS-L564?

If you fail to submit this form, it is considered incomplete, and your MAC will not process any claims until they receive it. If a physician has non physician owners or partners, owns the group practice they work for, or has contractual arrangements (buying/selling) with physicians, that physician must submit Form CMS-L564 as part of their enrollment.

What is Contractual Arrangement?

The contractual arrangement is defined as either buying/selling arrangements where a physician provides services to an entity and is paid by that entity.

What Is Form CMS-L564? | Filling Out, Usage & Submission

Q: What is Form CMS-L564

Form CMS-L564 is a document that physicians fill out when they have the following credentials: Non Physician owners or partners Own group practices Contractual arrangements (buying/selling arrangements) The purpose of the form is to determine whether or not a physician meets certain conditions that may allow them to be reimbursed.

Form CMS-L564 is a form that physicians complete to ensure they are in compliance with applicable Medicare billing requirements.

Physicians are required to complete the form when they are working for an entity that has non physician owners or partners, when they have their own group practice, or when they work for anyone who recruits them under a contractual arrangement.

Physicians must complete Form CMS-L564 on an annual basis.

How to Fill Out Form CMS-l564

Physicians who are required to complete Form CMS-L564 should have the following information available when completing the form:

Type of ownership or contractual arrangement with non physician owners or partners
Documentation that all parties involved in the business meet Medicare billing requirements, including physicians who are not based at your practice location or locations
Supporting documentation that all non physician owners or partners and additional locations meet the Medicare billing requirements (if applicable)
Documentation that any affiliated entities providing administrative, management, consulting, employment services and other services related to the practice is in compliance with CMS billing requirements
What types of covered Part B-based physician fee schedule services are being provided, whether inpatient or outpatient
What types of Part B-based covered drugs are being dispensed at your location(s)

You must submit Form CMS-L564 to the Medicare Administrative Contractor (MAC) or to the carrier within 30 days after completing this form.

You should receive a response from the MAC or carrier within 30 days of submitting Form CMS-L564.

When Should You Use Form CMS-L564

You must complete this form annually if you meet any of the following conditions:

Physician with non physician owners or partners working in FQHCs (Federally Qualified Health Centers) and RHCs (Rural Health Clinics)
Physician with non physician owners or partners working in their own group practices
Physicians who are recruited by another physician under a contractual arrangement (buying/selling arrangements)

You should complete this form if you work for any entity that recruits you under a contractual arrangement (buying/selling arrangements).

The requirement to submit Form CMS-L564 does not depend on whether or not the entity pays you, your ownership percentage in the organization, or how much time you spend working for them.

You may have other contractual arrangements with entities that are unrelated to your medical practice.

You are required to submit Form CMS-L564 if this arrangement involves providing physician services that are paid for by Medicare.

How to Submit Form CMS-l564

Physicians who are required to complete Form CMS-L564 should submit the form with their paperwork when enrolling as an FQHC or RHC, and at least once per year thereafter.

You can find additional information about submitting this form on the Medicare.gov website under the What You Need to Know About Enrolling as a Rural Health Clinic or Federally Qualified Health Center section.

You can submit this form using the following methods:

Paper form
Electronic form ( it must be saved as a .pdf)
EPIC Portal (electronic portal for MACs, carriers, and Medicare Administrative Contractors that allows electronic submission of forms to CMS)
Online Web Form

The Bottom Line

Physicians may have to complete Form CMS-L564 when they are working for an entity that has non physician owners or partners, when they have their own group practice, or when they work for anyone who recruits them under a contractual arrangement.

Physicians must complete this form on an annual basis.

The requirement to submit Form CMS-L564 does not depend on whether or not the entity pays you, your ownership percentage in the organization, or how much time you spend working for them.

It is best practice to complete this form before the start of each new Medicare fiscal year in order to ensure you are compliant with all requirements.

Form CMS-L564 FAQs