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Medicare Enrollment Application-For Eligible Ordering And Referring Physicians And Non-Physician Practitioners CMS-855O - Official Federal Forms
| Medicare Enrollment Application-For Eligible Ordering And Referring Physicians And Non-Physician Practitioners Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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MEDICARE ENROLLMENT APPLICATION REGISTRATION FOR ELIGIBLE ORDERING AND REFERRING PHYSICIANS AND NON-PHYSICIAN PRACTITIONERS CMS-855O SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION AND FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-1135 WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION Most physicians and non-physician practitioners enroll in the Medicare program to be reimbursed for the covered services they furnish to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, CMS requires certain physicians and non-physician practitioners to register in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. These physicians and non-physician practitioners do not and will not send claims to a Medicare Administrative Contractor for the services they furnish. The physicians and non-physician practitioners who may register in Medicare solely for the purpose of ordering and referring include, but are not limited to, those who are: · EmployedbyFederallyQualifiedHealthCenters · EmployedbytheDepartmentofVeterans (FQHC),RuralHealthClinics(RHC)orCriticalAccess Affairs (DVA) Hospitals (CAH) · EmployedbythePublicHealthService(PHS) · LicensedandNon-licensedInterns,Residentsand · EmployedbytheDepartmentofDefense Fellows in an approved medical residency program (DOD)/Tricare · Dentists,includingoralsurgeons · EmployedbytheIndianHealthService(IHS)or · Pediatricians a Tribal Organization Once registered, you will be placed on the Medicare Ordering and Referring Registry and will be deemed eligible to order and refer patients to Medicare enrolled providers and suppliers. Physicians and non-physician practitioners can apply to register for the sole purpose of ordering and referring items and/or services to beneficiaries in the Medicare program or make a change in their registration information using either: · The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or · The paper CMS-855O application. Be sure you are using the most current version. For additional information regarding the Medicare Ordering and Referring registration process, including Internet-based PECOS and to get a copy of the most current CMS-855O application, go to https://www.cms. gov/MedicareProviderSupEnroll. The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. See the last page of this application to read the Privacy Act Statement. NATIONAL PROVIDER IDENTIFIER INFORMATION The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). As a registering Medicare supplier, you must obtain an NPI prior to registering in Medicare. Applying for the NPI is a process separate from Medicare registration or enrollment. To obtain an NPI, you may apply online at https://NPPES. cms.hhs.gov/NPPES/Welcome.do. For more information about NPI enumeration, visit https://www.cms.gov/ NationalProvIdentStand. INSTRUCTIONS FOR COMPLETING THIS APPLICATION All information on this form is required with the exception of those fields specifically marked as "optional." Any field marked as optional is not required to be completed nor does it need to be updated or reported as a "change of information" as required in 42 CFR § 424.516. However, it is highly recommended that once reported, these fields be kept up-to-date. · Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred. · Complete all applicable sections and furnish your NPI. · Keep a copy of your completed Medicare registration application for your records. · Sign and date Section 8 of this application using blue ink. ACRONYMS COMMONLY USED IN THIS APPLICATION MAC: Medicare Administrative Contractor NPI: National Provider Identifier PECOS: Provider Enrollment Chain and Ownership System WHERE TO MAIL YOUR APPLICATION The MAC that services your State is responsible for processing your registration application. To locate the mailing address for your designated MAC, go to https://www.cms.gov/MedicareProviderSupEnroll. CMS-855O (01/13) American LegalNet, Inc. www.FormsWorkFlow.com 1 SECTION 1: BASIC INFORMATION A. REASON FOR SUBMITTING THIS APPLICATION Check one box and complete the sections of this application as indicated. You are registering for the sole purpose of ordering/referring Complete all sections You are currently registered solely to order and refer and are updating Complete Section 2A, all other applicable sections and Section 8 your information You are voluntarily withdrawing your Medicare registration to solely order and refer Complete Section 2A (Name, SSN and NPI) and Section 8 B. REASON YOU ARE REGISTERING SOLELY TO ORDER OR REFER You are registering in Medicare solely to order or refer because you are (check one): Employed by the DVA Non-physician practitioner not employed by any of the above Employed by the PHS Licensed intern resident or fellow not employed at Employed by the DOD/Tricare any of the above Employed by the IHS or a Tribal Organization Non-Licensed intern, resident or fellow not EmployedbyaMedicare-enrolledFQHC employed at any of the above Employed by a Medicare-enrolled RHC Dentist not employed by any of the above Employed by a Medicare-enrolled CAH Pediatrician not employed by any of the above Physician not employed by any of the above Other (Specify): _________________________________ SECTION 2: IDENTIFYING INFORMATION A. PERSONAL INFORMATION First Name Other Name, First Your name, date of birth, and social security number must match your social security record. Middle Initial Middle Initial Last Name Last Name Jr., Sr., M.D., etc. Jr., Sr., M.D., etc. Type of Other Name Former or Maiden Name Social Security Number (SSN) Professional Name Other (Describe):____________________________________ Gender Male Female National Provider Identifier (NPI) (Type 1 Individual) Date of Birth (mm/dd/yyyy) Medicare Identification Number (PTAN) (if issued) B. EDUCATIONAL INFORMATION Medical or other Professional School (Training Institution, if non-MD) Year of Graduation (yyyy) C. LICENSE/CERTIFICATION/REGISTRATION IN
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