| Reformatting of CMS 855R - Mapping Guide |
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| Current Section Location |
Current Section Header/Subheader/Information |
New Section Location |
New Section Header/Subheader/Information |
| Intro. Pages |
General Information |
stet |
Who Should Complete This Application |
| Intro. Pages |
Instructions For Completing And Submitting This Application |
stet |
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| Intro. Pages |
Additional Information |
stet |
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| Intro. Pages |
Mail Your Application |
stet |
Where To Mail Your Application |
| 1 |
Basic Information |
stet |
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| 2 |
Organization Receiving the Reassigned Benefits |
2 |
Individual Practitioner Who Is Reassigning Benefits |
| 3 |
Individual Practitioner Who Is Reassigning Benefits |
3 |
Organization/Group Receiving the Reassigned Benefits |
| 4 |
Authorization Statements |
4 |
Primary Practice Location |
| 4A |
Individual Practitioner |
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| 4B |
Authorized or Delegated Official of Group Practice/Clinic |
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| 5 |
For Future Use |
5 |
Contact Person |
| 6 |
For Future Use |
6 |
Signatures and Certification Statements |
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6A |
Individual Practitioner Certification Statement and Signature |
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6B |
Authorized or Delegated Official of the Organization/Group Certification Statement and Signature |
| 7 |
Contact Person |
n/a |
deleted |
| last page |
Medicare Supplier Enrollment Application Privacy Act Statement |
stet |
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