The following instructions have been provided to you as a guide
to help in the completion of your Provider Enrollment 855 application.
Use Form Guide To Determine Your Action With This
Application |
Complete These Required Sections |
| CMS 855B (Check applicable box) |
|
| New enrollee in Medicare |
- Complete all sections
- Ambulance suppliers must also complete Attachment
1
- IDTF suppliers must also complete Attachment 2
- In Section 4, enter your Medicare Identification
Number (if issued)
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
Enrolling in Another fee-for-service contractor's jurisdiction |
- Complete all sections
- Ambulance suppliers must also complete Attachment
1
- IDTF suppliers must also complete Attachment 2
- In Section 4, enter your Medicare Identification
Number (if issued)
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
| Reactivating you Medicare enrollment |
- Complete all sections
- Ambulance suppliers must also complete Attachment
1
- IDTF suppliers must also complete Attachment 2
- In Section 4, enter your Medicare Identification
Number (if issued)
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
| Voluntarily terminating your Medicare enrollment. (This is
not the same as “Opting Out” of the program) |
- Complete sections 1A, 2B1, 13 and
either 15 or 16
- If terminating an employment arrangementwith a physician
assistant, complete Sections 1A, 2G, 13, and
either 15 or 16.
- Document effective date of termination
- Document Medicare Identification Number(s) to Terminate
(if issued)
- Document NPI number (if issued)
|
| Changing your Medicare Information |
- Go to Section 1B
- Enter Medicare Identification Number
- Enter NPI
|
| Revalidating your Medicare enrollment |
- Complete all sections
- Ambulance suppliers must also complete Attachment
1
- IDTF suppliers must also complete Attachment 2
- In Section 4, enter your Medicare Identification Number
(if issued)
- In Section 4, enter NPI to be linked to your Medicare Identification
number.
|
| Section 1B |
|
| Identifying Information |
- 1,2 (complete only those sections that
are changing), 3, 13, and either 15 (if
you are an authorized 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
|
| Adverse Legal Actions/Convictions |
- 1,2B1, 3, 13 , and either 15 (if
you are an authorized 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.
|
| Practice Location Information, Payment Address & Medical
Record Storage Information |
- 1,2B1,3,4 (complete only those sections
that are changing), 13, and either 15 (if
you are an authorized 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.
|
| Change of Ownership (Hospitals, Portable X-Ray Suppliers & Ambulatory
Surgical Centers Only) |
- Complete all sections and provide a copy of the sales agreement
.
|
| Ownership Interest and/or Managing Control Information (Organizations) |
- 1,2B1,3,5,13 , and either 15 (if
you are an authorized 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.
|
| Ownership Interest and/or Managing Control Information (Individuals) |
- 1,2B1,3,6,13 , and either 15 (if
you are an authorized 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.
|
| Billing Agency Information |
- 1,2B1,3,8 (Complete only those sections
that are changing), 13, and either 15 (if
you are an authorized 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.
|
| Authorized Official(s) |
1,2B1,3,13 , and either 15 (if
you are an authorized 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. |
| Delegated Official(s) (Optional) |
1,2B1,3,13,15 and 16 |
| Attachment 1 - Ambulance Service Suppliers
(ONLY) |
|
| Geographic Area |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if you are the delegated
official
- Attachment 1(A)
|
| State License Information |
- 1,2A2,3,13 , and 15 if
you are the authorized official or 16 if you are the delegated
official
- Attachment 1(B)
|
| Paramedic Intercept Services Information |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if
you are the delegated official
- Attachment 1(C)
|
| Vehicle Information |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if you are the delegated
official
- Attachment 1(D)
|
| Attachment 2 - Independent Diagnostic Testing
Facilities (ONLY) |
|
| CPT-4 and HCPCS Codes |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if
you are the delegated official
- Attachment 2(B)
|
| Interpreting Physician Information |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if
you are the delegated official.
- Attachment 2(C)
|
| Personnel (Technicians) Who Perform Tests |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if you are the delegated
official
- Attachment 2(D)
|
| Supervising Physician(s) |
- 1,2A2,3,13, and 15 if
you are the authorized official or 16 if
you are the delegated official
- Attachment 2(E)
|
| CMS 855I (check applicable box) |
|
| New Enrollee in Medicare |
- Complete all sections
- In Section 4, enter your Medicare Identification
Number (if issued).
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
| Enrolling with another fee-for-service contractor |
- Complete all sections
- In Section 4, enter your Medicare Identification
Number (if issued).
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
| Reactivating your Medicare enrollment |
- Complete all sections
- In Section 4, enter your Medicare Identification
Number (if issued).
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
| Voluntarily terminating your Medicare enrollment |
- Complete sections 1A,13 and 15
- Physician Assistants must complete Sections 1A,2F,13 and 15
- Employers terminating Physician Assistants must complete Sections
1A,2G,13 and 15.
- Enter effective Date of Termination
- Enter Medicare Identification Number(s) to Terminate (if
issued)
- Enter National Provider Identifier (if issued)
|
| Changing your Medicare Information |
- Go to Section 1B
- Enter your Medicare Identification Number (if issued).
- Enter NPI.
|
| Revalidating your Medicare enrollment |
- Complete all sections
- In Section 4, enter your Medicare Identification
Number (if issued).
- In Section 4, enter NPI to be linked to
your Medicare Identification number.
|
| SECTION 1B |
|
| Identifying Information |
Complete 1,2 ( complete only those sections
thatare changing), 3,13 and 15 |
| Adverse Legal Actions/Convictions |
1,2A,3,13 and 15 |
| Practice Location Information, Payment Address and Medical
Record Storage Information |
1,2A,3,4 ( complete only those sections that
are changing), 13 and 15 |
| Individuals Having Managing Control |
1,2A,3,6,13, and 15 |
| Billing Agency Information |
1,2A,3,8 ( complete only those sections that
are changing), 13 and 15 |
| CMS 855R (check applicable box) |
|
| Enrolling or currently enrolled in Medicare and will be reassigning
your benefits to this supplier for the first time |
- Complete all sections
- Enter effective date (mm/dd/yyyy)
|
| Individual practitioner terminating a reassignment |
- Complete sections 1,2,3, and 4A
- Enter effective date (mm/dd/yyyy)
|
| Organization terminating a reassignment |
- Complete sections 1,2,3, and 4B
- Enter effective date (mm/dd/yyyy)
|
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