| Reformatting of CMS 855I - Mapping Guide |
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| Current Section Location |
Current Section Header/Subheader/Information |
New Section Location |
New Section Header/Subheader/Information |
| Intro. Pages |
Who Should Complete This Application |
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| Intro. Pages |
Billing Number Information |
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| Intro. Pages |
Instructions For Completing And Submitting This Application |
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| Intro. Pages |
Avoid Delays In Your Enrollment |
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| Intro. Pages |
Additional Information |
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| Intro. Pages |
Mail Your Application |
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| Intro. Pages |
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Acronyms Commonly Used In This Application (new) |
| 1 |
Basic Information |
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| 1A |
Check one box and complete the required sections. |
1A |
Reason For Submitting This Application |
| 1B |
Check all that apply and complete the required sections. |
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| 2 |
Identifying Information |
2 |
Personal Identifying Information |
| 2A |
Personal Information |
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12 |
Important Address Information (new section header) |
| 2B |
Correspondence Address |
12A |
Correspondence Mailing Address |
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13B |
Revalidation Request Package Mailing Address (new) |
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2B |
License/Certification Information (new sub-section 2B header, information previously collected in Section 2A) |
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2B1 |
License Information |
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2B2 |
Certification Information |
| 2C |
Resident/Fellow Status |
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| 2C1 |
Are you currently in an approved training program as…? |
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| 2C2 |
Are the services that you render at the facility shown in Section 2C1 part of your requirements…? |
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| 2C3 |
Do you also render services at other facilities or practice locations? |
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| 2C4 |
Are the services that you render in any of the practice locations you will be reporting…? |
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4 |
Medical Specialty Information (new section 4 header) |
| 2D1 |
Physician Specialty |
4A |
Physician Specialty |
| 2D2 |
Non-Physician Specialty |
4B |
Non-Physician Specialty |
| 2E |
Physician Assistants: Establishing Employment Arrangement(s) |
5A |
Physician Assistants: Establishing Employment Arrangement(s) |
| 2F |
Physician Assistants: Terminating Employment Arrangement(s) |
5B |
Physician Assistants: Terminating Employment Arrangement(s) |
| 2G |
Employer Terminating Employment Arrangement with One or More Physician Assistants |
5C |
Employer Terminating Employment Arrangement With One Or More Physician Assistants |
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6 |
Psychologist Information (new section 6 header) |
| 2H |
Clinical Psychologists |
6A |
Clinical Psychologists |
| 2I |
Psychologists Billing Independently |
6B |
Psychologists Billing Independently |
| 2I1 - 4 |
Billing/Private Practice questions (re: 2I above) |
6B1-4 |
Billing/Private Practice questions (re: 6B above) |
| 2J |
Physical Therapists/Occupational Therapists in Private Practice (PT/OT) |
7 |
Physical/Occupational Therapists Information |
| 2J1-5 |
Individual Practice questions (re: 2J above) |
7a-e |
Individual Practice questions (re: sec. 7) |
| 2K |
Nurse Practitioners and Certified Clinical Nurse Specialists |
8 |
Nurse/Nurse Practitioner Information |
| 2L |
Advanced Diagnostic Imaging (ADI) Suppliers Only |
n/a |
deleted |
| 3 |
Final Adverse Legal Actions/Convictions |
3 |
Final Adverse Legal Actions |
| 4 |
Practice Location Information |
9 |
Private Practice Location Information |
| 4A |
Establishing a Professional Corporation, Professional Association, Limited Liability Company, etc. |
11A |
Establishing A Professional Corporation, Professional Association, Limited Liability Company, etc. |
| 4A1 - 2 |
Final Adverse Legal Action History (of 4A above) |
11E |
Final Adverse Legal Action History (re: 12A above) |
| 4B |
Individual Affiliations |
15 |
Group/Clinic Affiliation Information |
| 4B1 - 3 |
Reassignment/Payment Questions |
15A-E |
Reassignment/Payment Questions (information previously collected in Section 4) |
| 4C |
Practice Location Information |
9A |
Private Practice Location Identification |
| 4D |
Rendering Services In Patients’ Homes |
9C |
Rendering Services In Patients’ Homes |
| 4E |
Where Do You Want Remittance Notices or Special Payments Sent? |
12C |
Remittance Notices/Special Payments Mailing Address |
| 4F |
Employer ID Number Information |
11B |
Employer Identification Number Information |
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11C |
Business Structure (information previously collected in Section 4A) |
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11D |
Internal Revenue Service Registration (information previously collected in Section 4A) |
| 4G |
Where Do You Keep Patients’ Medical Records? |
12D |
Medicare Beneficiary Medical Records Storage Address |
| 4H |
Unique Circumstances |
9B |
Unique Circumstances |
| 5 |
For Future Use |
5 |
Physician Assistant Information |
| 6 |
Individuals Having Managing Control |
10 |
Managing Employee Information |
| 6A |
Managing Employee identifying information |
10A |
Managing Employee identifying information |
| 6B |
Final Adverse Legal Action History (of 6A above) |
10B |
Final Adverse Legal Action History (re: 11A above) |
| 6B1 - 2 |
Final Adverse Legal Action questions (of 6A above) |
10B1-2 |
Final Adverse Legal Action questions (re: 11A above) |
| 7 |
For Future Use |
n/a |
delete |
| 8 |
Billing Agency Information |
13 |
Billing Agency Information |
| 9 |
For Future Use |
n/a |
delete |
| 10 |
For Future Use |
n/a |
delete |
| 11 |
For Future Use |
n/a |
delete |
| 12 |
For Future Use |
11 |
Private Practice Business Information |
| 13 |
Contact Person |
14 |
Contact Person |
| 14 |
Penalties For Falsifying Information |
17 |
Penalties For Falsifying Information On This Enrollment Application |
| 15 |
Certification Statement |
18 |
Signature And Certification Statement |
| 16 |
For Future Use |
16 |
Supporting Documents |
| 17 |
Supporting Documents |
n/a |
deleted |
| last page |
Medicare Supplier Enrollment Privacy Act Statement |
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