CMS-855(I) Medicare Enrollment Application -Physicians and Non-Phys

Medicare Enrollment Application

CMS-855I(6-30-11)

Medicare Enrollment Application

OMB: 0938-0685

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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.

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:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• The paper enrollment application process (e.g., CMS 855I).
For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go
to http://www.cms.gov/MedicareProviderSupEnroll/.
Physicians and non-physician practitioners who are enrolled in the Medicare program, but have not
submitted the CMS 855I since 2003, are required to submit a Medicare enrollment application (i.e.,
Internet-based PECOS or the CMS 855I) as an initial application when reporting a change for the first time.

All physicians, as well as all non-physician practitioners listed below, must complete this application to
initiate the enrollment process:
Anesthesiology Assistant
Mass immunization roster biller
Psychologist, Clinical
Audiologist
Nurse practitioner
Psychologist billing
Certified nurse midwife
Occupational therapist in
independently
Certified registered nurse
private practice
Registered Dietitian or
anesthetist
Physical therapist in
Nutrition Professional
Clinical nurse specialist
private practice
Speech Language Pathologist
Clinical social worker
Physician assistant

If your supplier type is not listed above, contact your designated fee-for-service contractor before you
submit this application.

Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
• An individual practitioner who will provide services in a private setting.
• An individual practitioner who will provide services in a group setting. If you plan to render all of
your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17
of this application.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-forservice contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory
serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you
have added or changed a practice location).
• An individual who has formed a professional corporation, professional association, limited liability
company, etc., of which you are the sole owner.
If you provide services in a group/organization setting, you will also need to complete a separate
application, the CMS-855R, to reassign your benefits to each organization. If you terminate your
association with an organization, use the CMS-855R to submit that change.

CMS-855I (07/11)

billing number information
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and
is assigned by the National Plan and Provider Enumeration System (NPPES). 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. Applying for the NPI is a process separate from Medicare
enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.gov. For more information about
NPI enumeration, visit www.cms.gov/NationalProvIdentStand.
The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN)
or Medicare Legacy Number, is a generic term for any number other than the NPI that is used to identify a
Medicare supplier.

INSTRUCTIONS FOR COMPLETING and submitting THIS APPLICATION
Type or print all information so that it is legible. Do not use pencil.
• Report additional information within a section by copying and completing that section for each
additional entry.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your own records.
• Send the completed application with original signatures and all required documentation to your
designated fee-for-service contractor.

avoid delays in your enrollment
To avoid delays in the enrollment process, you should:
• Complete all required sections.
• Ensure that the correspondence address shown in Section 2 is the supplier’s address.
• Enter your NPI in the applicable sections.
• Enter all applicable dates.
• Send the completed application with all supporting documentation to your designated
fee-for-service contractor.

ADDITIONAL INFORMATION
For additional information regarding the Medicare enrollment process, visit www.cms.gov/
MedicareProviderSupEnroll.

The fee-for-service contractor may request, at any time during the enrollment process, documentation to
support and validate information reported on the application. You are responsible for providing this
documentation in a timely manner.

Certain information you provide on this form is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6),
respectively. For more information, see the last page of this application to read the Privacy Act Statement.

MAIL YOur APPLICATION
The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative
contractor) that services your State is responsible for processing your enrollment application. To locate the
mailing address for your fee-for-service contractor, go to www.cms.gov/MedicareProviderSupEnroll.

CMS-855I (07/11)

SECTION 1: basic information
A. Check one box and complete the required sections.

Since physician assistants do not complete Section 4, all physician assistants must furnish their Medicare
Identification Number (if issued) and their NPI here:
Medicare Identification Number(s):_______________________ NPI:_______________________
If you are reassigning all of your Medicare benefits per section 4B1 of this application, furnish your
Medicare Identification Number (if issued) and your individual (Type 1) NPI here:

Medicare Identification Number(s):_______________________ NPI:_______________________
Reason for application

Billing Number information

You are a new enrollee in
Medicare

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number
in Section 4.

Complete all applicable
sections

You are enrolling with
another fee-for-service
contractor

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number
in Section 4.

Complete all applicable
sections

You are reactivating your
Medicare enrollment

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number
in Section 4.

Complete all applicable
sections

You are voluntarily
terminating your Medicare
enrollment

You are changing your
Medicare information

Effective Date of Termination:

Medicare Identification Number(s) to
Terminate (if issued):

REQUIRED SECTIONS

Sections 1A, 13 and 15

Physician Assistants must
complete Sections 1A, 2F, 13
and 15

National Provider Identifier (if issued):

Employers terminating
Physician Assistants must
complete Sections 1A, 2G, 13
and 15

Medicare Identification Number
(if issued):

Go to Section 1B

NPI:

You are revalidating your
Medicare enrollment

CMS-855I (07/11)

Enter your Medicare Identification
Number (if issued) and the NPI you
would like to link to this number
in Section 4.

Complete all applicable
sections

SECTION 1: basic information (Continued)
B. Check all that apply and complete the required sections.
Required Sections

Identifying Information

1, 2 (complete only those sections that are
changing), 3, 13 and 15

Final Adverse 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-855I (07/11)

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

Professional Name

Date of Birth (mm/dd/yyyy)

State of Birth

Gender

Male

Other (Describe):____________________________________
Country of Birth

Social Security Number

Female

Medical or other Professional School (Training
Institution, if non-MD)

Year of Graduation (yyyy)

DEA Number (if applicable)

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

B. Correspondence Address

Provide contact information for the person shown in Section 2A above. Once enrolled, the information
provided below will be used by the fee-for-service contractor if it needs to contact you directly. This
address cannot be a billing agency’s address.
Mailing Address Line 1 (Street Name and Number)

Mailing Address Line 2 (Suite, Room, etc.)

City/Town

Telephone Number

CMS-855I (07/11)

State

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

SECTION 2: Identifying Information (Continued)
C. Resident/Fellow Status

1. Are you currently in an approved training program as:
a. A resident?
b. In a fellowship program?

YES
YES

NO
NO

• If NO, skip to Section 2D.
• If YES to either of the above questions, provide the name and address of the
facility where you are a resident or fellow on the following lines:
_ ___________________________________________________________________________________
_ ___________________________________________________________________________________
_ ___________________________________________________________________________________
YES

3. Do you also render services at other facilities or practice locations?
IF YES, you must report these practice locations in Section 4.

YES

4. Are the services that you render in any of the practice locations you will
be reporting in Section 4 part of your requirements for graduation from
a residency or fellowship program?

YES

IF YES, has the teaching hospital reported in Section 2C1 above agreed to
incur all or substantially all of the costs of training in the non-hospital facility.

YES

2. Are the services that you render at the facility shown in Section 2C1
part of your requirements for graduation from a formal residency
or fellowship program?
Date of Completion:____________. If your completion date is prior to the
beginning date for your practice in Section 4, skip to Section 2D.

CMS-855I (07/11)

SECTION 2: Identifying Information (Continued)
D. 1. Physician Specialty

Designate your primary specialty and all secondary specialty(s) below using:
P=Primary S=Secondary

You may select only one primary specialty. You may select multiple secondary specialties. A physician
must meet all Federal and State requirements for the type of specialty(s) checked.
Addiction medicine

Hematology/Oncology

Palliative Care

Anesthesiology

Infectious disease

Pediatric medicine

Allergy/Immunology
Cardiac Electrophysiology
Cardiac surgery

Cardiovascular disease
(Cardiology)
Chiropractic

Colorectal surgery
(Proctology)

Critical care (Intensivists)
Dermatology

Diagnostic radiology

Emergency medicine
Endocrinology

Family practice

Gastroenterology
General practice
General surgery

Geriatric medicine

Gynecological oncology
Hand surgery
Hematology

CMS-855I (07/11)

Hospice

Internal medicine

Interventional Pain
Management

Interventional radiology

Pathology

Peripheral vascular disease
Physical medicine
and rehabilitation

Maxillofacial surgery

Plastic and
reconstructive surgery

Nephrology

Preventive medicine

Neuropsychiatry

Psychiatry (geriatric)

Nuclear medicine

Radiation oncology

Ophthalmology

Sports Medicine

Oral surgery (Dentist only)

Thoracic surgery

Osteopathic Manipulative
Medicine

Vascular surgery

Medical oncology

Podiatry

Neurology

Psychiatry

Neurosurgery

Pulmonary disease

Obstetrics/Gynecology

Rheumatology

Optometry

Surgical oncology

Orthopedic surgery

Urology

Otolaryngology

Pain Management

Undefined physician type
(Specify):__________________

SECTION 2: Identifying Information (Continued)
D. 2. Non–Physician Specialty

If you are a non-physician practitioner, check the appropriate box to indicate your specialty.

All non-physician practitioners must meet specific licensing, educational, and work experience
requirements. If you need information concerning the specific requirements for your specialty, contact the
Medicare fee-for-service contractor.
Check only one of the following: If you want to enroll as more than one non-physician specialty type,

you must submit a separate CMS-855I application for each.
Anesthesiology assistant
Audiologist
Certified nurse midwife

Certified registered nurse anesthetist
Clinical nurse specialist
Clinical social worker

Mass immunization roster biller
Nurse practitioner

Occupational therapist in private practice
Physical therapist in private practice
Physician assistant

Psychologist, clinical

Psychologist billing independently

Registered dietitian or nutrition professional
Speech Language Pathologist

Undefined non-physician practitioner type (Specify):
_ _______________________________________
_ _______________________________________
_ _______________________________________

CMS-855I (07/11)

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)

Complete this section if you are a physician assistant discontinuing your employment with a practice.
EMPLOYER’S NAME

EFFECTIVE DATE
OF EMPLOYMENT

EMPLOYER’S MEDICARE
IDENTIFICATION NUMBER
(IF ISSUED)

EMPLOYER’S
NPI

EMPLOYER’S
EIN

G. Employer Terminating Employment Arrangement with One or More Physician Assistants

This section should be used by an individual who has incorporated or is a sole proprietor, and who is
discontinuing their employment arrangement with a physician assistant.
PHYSICIANS ASSISTANT’S NAME

CMS-855I (07/11)

EFFECTIVE DATE
OF DEPARTURE

PHYSICIANS ASSISTANT’S
MEDICARE IDENTIFICATION
NUMBER A (IF ISSUED)

PHYSICIANS
ASSISTANT’S NPI

SECTION 2: Identifying Information (Continued)
H. Clinical Psychologists

Do you hold a doctoral degree in psychology?
I f YES, furnish the field of your psychology degree__________________________

YES

1 . Do you render services of your own responsibility free from the administrative
control of an employer such as a physician, institution, or agency?

YES

2. Do you treat your own patients?

3 . Do you have the right to bill directly, and to collect and
retain the fee for your services?

YES

4. Is this private practice located in an institution?
If YES to question 4 above, please answer questions “a” and “b” below.
a) If your private practice is located in an institution, is your office confined
to a separately identified part of the facility that is used solely as your office
and cannot be construed as extending throughout the entire institution?
b) If your private practice is located in an institution, are your services also
rendered to patients from outside the institution or facility where your
office is located?

YES

Attach a copy of the degree with this application.

I. Psychologists Billing Independently

J. Physical Therapists/Occupational Therapists in Private Practice (PT/OT)

The following questions only apply to your individual practice. They do not apply if you are reassigning
all of your benefits to a group/organization.
1. Are all of your PT/OT services only rendered in the patients’ homes?

YES

3. Do you own, lease, or rent your private office space?

YES

2. Do you maintain private office space?

YES

4. Is this private office space used exclusively for your private practice?

5. Do you provide PT/OT services outside of your office and/or patients’ homes?

If you respond YES to any of the questions 2–5 above, attach a copy of the lease
agreement that gives you exclusive use of the facility for PT/OT services.
K. Nurse Practitioners and Certified Clinical Nurse Specialists

Are you an employee of a Medicare skilled nursing facility (SNF) or of another
entity that has an agreement to provide nursing services to a SNF?

YES
YES

YES

NO
NO
NO

If yes, include the SNF’s name and address.
Name

Street Address

City

CMS-855I (07/11)

State

Zip

SECTION 2: Identifying Information (Continued)
L. Advanced Diagnostic Imaging (ADI) Suppliers Only

This section must be completed by all individual practitioners that also furnish and will bill Medicare
for ADI services. All individual practitioners furnishing ADI services MUST be accredited in each ADI
Modality checked below to qualify to bill Medicare for those services.
Check each ADI Modality that you will furnish and the name of the Accrediting Organization that
accredited you for that ADI Modality.
Magnetic Resonance Imaging (MRI)
Name of Accrediting Organization for MRI

Effective Date of Current Accreditation (mm/dd/yyyy)

Expiration Date of Current Accreditation (mm/dd/yyyy)

Computed Tomography (CT)
Name of Accrediting Organization for CT

Effective Date of Current Accreditation (mm/dd/yyyy)

Expiration Date of Current Accreditation (mm/dd/yyyy)

Nuclear Medicine (NM)
Name of Accrediting Organization for NM

Effective Date of Current Accreditation (mm/dd/yyyy)

Expiration Date of Current Accreditation (mm/dd/yyyy)

Positron Emission Tomography (PET)
Name of Accrediting Organization for PET

Effective Date of Current Accreditation (mm/dd/yyyy)

CMS-855I (07/11)

Expiration Date of Current Accreditation (mm/dd/yyyy)

SECTION 3: Final ADVERSE LEGAL ACTIONS/CONVICTIONS
This section captures information on final adverse legal actions, such as convictions, exclusions, revocations,
and suspensions. All applicable final adverse actions must be reported, regardless of whether any records
were expunged or any appeals are pending.
Convictions

1. The provider, supplier, or any owner of the provider or supplier was, within the last 10 years preceding
enrollment or revalidation of enrollment, convicted of a Federal or State felony offense that CMS has
determined to be detrimental to the best interests of the program and its beneficiaries. Offenses include:

Felony crimes against persons and other similar crimes for which the individual was convicted,
including guilty pleas and adjudicated pre-trial diversions; financial crimes, such as extortion,
embezzlement, income tax evasion, insurance fraud and other similar crimes for which the
individual was convicted, including guilty pleas and adjudicated pre-trial diversions; any felony
that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit
that results in a conviction of criminal neglect or misconduct); and any felonies that would result in
a mandatory exclusion under Section 1128(a) of the Social Security Act.

2. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or
service under Medicare or a State health care program, or (b) the abuse or neglect of a patient in

connection with the delivery of a health care item or service.

3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement,

breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health
care item or service.

4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with or
obstruction of any investigation into any criminal offense described in 42 C.F.R. Section

1001.101 or 1001.201.
5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful
manufacture, distribution, prescription, or dispensing of a controlled substance.

Exclusions, Revocations, or Suspensions

1. Any revocation or suspension of a license to provide health care by any State licensing authority.
This includes the surrender of such a license while a formal disciplinary proceeding was pending
before a State licensing authority.

2. Any revocation or suspension of accreditation.

3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or
State health care program, or any debarment from participation in any Federal Executive Branch
procurement or non-procurement program.

4. Any current Medicare payment suspension under any Medicare billing number.

5. Any Medicare revocation of any Medicare billing number.

CMS-855I (07/11)

SECTION 3: Final ADVERSE LEGAL ACTIONS/CONVICTIONS (Continued)
Final ADVERSE Legal Action HISTORY

1. Have you, under any current or former name or business identity, ever had a final adverse legal action
listed on page 12 of this application imposed against you?

YES–Continue Below NO–Skip to Section 4

2. If yes, report each final adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.

Attach a copy of the final adverse legal action documentation and resolution.

Final Adverse LEGAL Action

CMS-855I (07/11)

Date

Taken By

Resolution

SECTION 4: PRACTICE LOCATION information
A. Establishing a Professional Corporation, Professional Association, Limited Liability Company, etc.

If you are the sole owner of a professional corporation, a professional association, or a limited liability
company, and will bill Medicare through this business entity, complete this section 4A, skip to Section 4C,
and complete the remainder of the application with information about your business entity.
Legal Business Name as Reported to the Internal Revenue Service

Tax Identification Number

Medicare Identification Number (if issued)

NPI

Incorporation Date (mm/dd/yyyy) (if applicable)

State Where Incorporated (if applicable)

Is this supplier an Indian Health Facility enrolling with the designated Indian Health Services (IHS) Medicare
Administrative Contractor (MAC)?
Yes
No
Identify the type of organizational structure of this provider/supplier (Check one)
Corporation

Limited Liability Company

Partnership

Sole Proprietor

Other (Specify): ____________

Identify how your business is registered with the IRS. (Note: If your business is a Federal and/or State
government provider or supplier, indicate “Non-Profit” below.)
Proprietary

Non-Profit

Note: If a checkbox indicating Proprietaryship or non-profit status is not completed, the provider/supplier
will be defaulted to “Proprietary.”

Final ADVERSE Legal Action HISTORY
1. Has your organization, under any current or former name or business identity, ever had any of the
final adverse legal actions listed on page 12 of this application imposed against it?

YES–Continue Below NO–Skip to Section 4B

2. If yes, report each final adverse legal action, when it occurred, the Federal or State agency or the court/
administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse legal action documentation and resolution.

Final Adverse LEGAL Action

Date

Taken By

Resolution

If you are the sole owner of a professional corporation, a professional association, or a limited
liability company, and will bill Medicare through this business entity, you do not need to complete a
CMS-855R that reassigns your benefits to the business entity.
B. Individual Affiliations

Complete this section with information about your private practice and group affiliations.
Furnish the requested information about each group/organization to which you will reassign your benefits.
In addition, either you or each group/organization reported in this section must complete and submit a
CMS 855R(s) (Individual Reassignment of Benefits) with this application. Reassigning benefits means that
you are authorizing the group/organization to bill and receive payment from Medicare for the services you
have rendered at the group/organization’s practice location.
If you are an individual who is reassigning all of your benefits to a group, neither you nor the group needs
to submit a CMS-588 (Electronic Funds Transfer Authorization Agreement) to facilitate that reassignment.
CMS-855I (07/11)

SECTION 4: PRACTICE LOCATION information (Continued)
1. If you are reassigning all of your payments to another group or organization furnish the name,
Medicare identification number(s) and NPI of each group or organization below and proceed to
Section 13.

2. If any of your payments are part of your private practice and a group or organization furnish the name
and Medicare identification number(s) and NPI of each group or organization below and continue to
Section 4C (where you will enter your private practice information).
3. If you are not reassigning all or any of your payments to another group or organization, skip to
Section 4C with information about your private practice.
a) Name of Group/Organization