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
5. 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)4. 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.
About the Author
True Tamplin, BSc, CEPF®
True Tamplin is a published author, public speaker, CEO of UpDigital, and founder of Finance Strategists.
True is a Certified Educator in Personal Finance (CEPF®), a member of the Society for Advancing Business Editing and Writing, contributes to his financial education site, Finance Strategists, and has spoken to various financial communities such as the CFA Institute, as well as university students like his Alma mater, Biola University, where he received a bachelor of science in business and data analytics.