Medicare Enrollment Application Physicians And Non-Physician Practitioners {CMS 855I} | Pdf Fpdf Doc Docx | Official Federal Forms

Medicare Enrollment Application Physicians And Non-Physician Practitioners {CMS 855I}

Official Federal Forms/Centers For Medicare And Medicaid Services/
Medicare Enrollment Application Physicians And Non-Physician Practitioners {CMS 855I} | Pdf Fpdf Doc Docx | Official Federal Forms

Medicare Enrollment Application Physicians And Non-Physician Practitioners Form

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This is a Official Federal Forms form that can be used for Centers For Medicare And Medicaid Services.

Last updated: 8/30/2011

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MEDICARE ENROLLMENT APPLICATION PHYSICIANS AND NON-PHYSICIAN PRACTITIONERS CMS-855I SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION. SEE PAGE 2 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION. SEE PAGE 26 TO FIND THE LIST OF THE SUPPORTING DOCUMENTATION THAT MUST BE SUBMITTED WITH THIS APPLICATION. American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0685 WHO SHOULD COMPLETE THIS APPLICATION Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either: to http://www.cms.gov/MedicareProviderSupEnroll/. initiate the enrollment process: Anesthesiology Assistant Audiologist Nurse practitioner independently Registered Dietitian or Nutrition Professional anesthetist Physical therapist in Physician assistant and you are: CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 1 BILLING NUMBER INFORMATION As a Medicare healthcare supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enrollment information. https://NPPES.cms.gov www.cms.gov/NationalProvIdentStand INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION AVOID DELAYS IN YOUR ENROLLMENT ADDITIONAL INFORMATION www.cms.gov/ MedicareProviderSupEnroll. MAIL YOUR APPLICATION www.cms.gov/MedicareProviderSupEnroll. CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 2 SECTION 1: BASIC INFORMATION A. Check one box and complete the required sections. REASON FOR APPLICATION BILLING NUMBER INFORMATION (if issued) REQUIRED SECTIONS new enrollee in Medicare Complete all applicable sections enrolling with another fee-for-service contractor (if issued) Complete all applicable sections reactivating your Medicare enrollment (if issued) Complete all applicable sections voluntarily terminating your Medicare enrollment Effective Date of Termination: 1A, 13 and 15 Physician Assistants must 1A, 2F, 13 and 15 Physician Assistants must 1A, 2G, 13 and 15 1B Medicare Identification Number(s) to Terminate (if issued): National Provider Identifier (if issued): changing your Medicare information Medicare Identification Number (if issued): NPI: revalidating your Medicare enrollment (if issued) Complete all applicable sections CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 3 SECTION 1: BASIC INFORMATION (Continued) B. Check all that apply and complete the required sections. REQUIRED SECTIONS 1, 2 3, 13 and 15 1, 2A, 3, 13 and 15 1, 2A, 3, 4 13 and 15 1, 2A, 3, 6, 13, and 15 1, 2A, 3, 8 13 and 15 that are that are CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 4 SECTION 2: IDENTIFYING INFORMATION A. Personal Information: Your name, date of birth, and social security number must coincide with the information on your social security record. First Name Middle Initial Last Name Jr., Sr., M.D., D.O., etc. Other Name, First Middle Initial Last Name Jr., Sr., M.D., D.O., etc. Type of Other Name Former or Maiden Name Date of Birth (mm/dd/yyyy) Professional Name State of Birth Other (Describe):____________________________________ Country of Birth Gender Social Security Number Male Female Year of Graduation (yyyy) DEA Number (if applicable) Medical or other Professional School (Training Institution, if non-MD) License Information License Not Applicable License Number State Where Issued Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy) Certification Information Certification Not Applicable Certification Number State Where Issued Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy) New Patient Status Information Do you accept new Medicare patients? Yes No B. Correspondence Address Mailing Address Line 1 (Street Name and Number) Mailing Address Line 2 (Suite, Room, etc.) City/Town State ZIP Code + 4 Telephone Number Fax Number (if applicable) E-mail Address (if applicable) CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 5 SECTION 2: IDENTIFYING INFORMATION (Continued) C. Resident/Fellow Status CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 6 SECTION 2: IDENTIFYING INFORMATION (Continued) D. 1. Physician Specialty P=Primary S=Secondary Addiction medicine Pathology Anesthesiology Pediatric medicine Physical medicine Management Plastic and Maxillofacial surgery Medical oncology Nephrology Neurology Dermatology Diagnostic radiology Neuropsychiatry Neurosurgery Nuclear medicine Family practice Gastroenterology General practice General surgery Geriatric medicine Gynecological oncology Medicine (Specify) Podiatry Psychiatry Pulmonary disease Radiation oncology Rheumatology Vascular surgery Pain Management CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 7 SECTION 2: IDENTIFYING INFORMATION (Continued) D. 2. Non­Physician Specialty Check only one of the following: Anesthesiology assistant Audiologist Nurse practitioner Physician assistant Registered dietitian or nutrition professional (Specify): CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 8 SECTION 2: IDENTIFYING INFORMATION (Continued) E. Physician Assistants: Establishing Employment Arrangement(s) EMPLOYER'S NAME EFFECTIVE DATE OF EMPLOYMENT EMPLOYER'S MEDICARE IDENTIFICATION NUMBER (IF ISSUED) EMPLOYER'S NPI EMPLOYER'S EIN F. Physician Assistants: Terminating Employment Arrangement(s) EMPLOYER'S MEDICARE IDENTIFICATION NUMBER (IF ISSUED) EMPLOYER'S NAME EFFECTIVE DATE OF EMPLOYMENT EMPLOYER'S NPI EMPLOYER'S EIN G. Employer Terminating Employment Arrangement with One or More Physician Assistants PHYSICIANS ASSISTANT'S NAME EFFECTIVE DATE OF DEPARTURE PHYSICIANS ASSISTANT'S MEDICARE IDENTIFICATION NUMBER A (IF ISSUED) PHYSICIANS ASSISTANT'S NPI CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 9 SECTION 2: IDENTIFYING INFORMATION (Continued) H. Clinical Psychologists I. Psychologists Billing Independently If YES to a separately identified part of the facility that is used solely as your office J. Physical Therapists/Occupational Therapists in Private Practice (PT/OT) If you respond YES to any of the questions 2­5 above K. Nurse Practitioners and Certified Clinical Nurse Specialists Name Street Address City State Zip CMS-855I (07/11) American LegalNet, Inc. www.FormsWorkFlow.com 10 SECTION 2: IDENTIFYING INFORMATION (Continued) L. Advanced Diagnostic Imaging (ADI) Suppliers Only Ma