855I Medicare Enrollment Application -Physicians and Non-Phys

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MEdiCarE EnrollMEnt aPPliCation

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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.

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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.

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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)

1

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

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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

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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)

2

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:_______________________
billing nuMbEr inforMation

You are a new enrollee in
Medicare

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

You are enrolling with
another fee-for-service
contractor

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

You are reactivating your
Medicare enrollment

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

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You are voluntarily
terminating your Medicare
enrollment

Effective Date of Termination:

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

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You are changing your
Medicare information

rEQuirEd SECtionS

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rEaSon for aPPliCation

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 Complete all sections
Number (if issued) and the NPI you
would like to link to this number
in Section 4.

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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
1, 2A, 3, 6, 13, and 15

Billing Agency Information

1, 2A, 3, 8 (complete only those sections that are
changing), 13 and 15

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Individuals Having Managing Control

CMS-855I (07/11)

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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
Year of Graduation (yyyy)

DEA Number (if applicable)

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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)

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Certification information
Certification Not Applicable

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Certification Number

Effective Date (mm/dd/yyyy)

State Where Issued

Expiration/Renewal Date (mm/dd/yyyy)

new Patient Status information
Do you accept new patients?

Yes

No

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)

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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

NO

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

YES

NO

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

NO

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

NO

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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?

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Date of Completion:____________. If your completion date is prior to the
beginning date for your practice in Section 4, skip to Section 2D.

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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

Pediatric medicine

Anesthesiology

Internal medicine

Physical medicine
and rehabilitation

Allergy/Immunology

Infectious disease

Cardiac Electrophysiology

Interventional Pain
Management

Peripheral vascular disease

Interventional radiology
Maxillofacial surgery

Podiatry

Preventive medicine

Colorectal surgery

(Proctology)

Medical oncology
Nephrology

Psychiatry

Neuropsychiatry

Pulmonary disease

Nuclear medicine

Rheumatology

Ophthalmology

Surgical oncology

Chiropractic

Critical care (Intensivists)
Dermatology

Diagnostic radiology

Emergency medicine
Family practice

Gastroenterology
General practice

Psychiatry (geriatric)

Neurosurgery

Radiation oncology

Obstetrics/Gynecology

Sports Medicine

Optometry

Thoracic surgery

Orthopedic surgery

Vascular surgery

Oral surgery (Dentist only)

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General surgery

Neurology

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Endocrinology

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Cardiovascular disease
(Cardiology)

Plastic and
reconstructive surgery

Cardiac surgery

Geriatric medicine

Osteopathic Manipulative
Medicine

Hand surgery

Pain Management

Gynecological oncology
Hematology

CMS-855I (07/11)

Otolaryngology

Urology

Undefined physician type
(Specify):__________________

Pathology

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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.

This section captures information on final adverse 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. Enrolled suppliers are required to report all Final Adverse

Actions/Convictions within 30 days of the reportable event.

Anesthesiology assistant
Audiologist

Certified nurse midwife

Clinical nurse specialist
Clinical social worker

Mass immunization roster biller
Nurse practitioner

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Certified registered nurse anesthetist

Occupational therapist in private practice
Physician assistant

Psychologist, clinical

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Physical therapist in private practice

Psychologist billing independently

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Registered dietitian or nutrition professional
Speech Language Pathologist

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

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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 MEdiCarE
idEntifiCation nuMbEr
(if iSSuEd)

EMPloyEr’S
nPi

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EffECtivE datE
of EMPloyMEnt

EMPloyEr’S
Ein

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EMPloyEr’S naME

g. Employer terminating Employment arrangement with one or More Physician assistants

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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

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SECtion 2: idEntifying inforMation (Continued)
h. Clinical Psychologists

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

YES

NO

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

NO

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

YES

NO

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

NO

YES

NO

YES

NO

Attach a copy of the degree with this application.

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i. Psychologists billing independently

NO

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?

Do you maintain private office space?
2.

YES

NO

YES

NO

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YES

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

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

D

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

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

NO

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

Street Address

City

CMS-855I (07/11)

State

Zip

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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)

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Name of Accrediting Organization for CT

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

nuclear Medicine (nM)

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

Name of Accrediting Organization for NM

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

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

Positron Emission tomography (PEt)

D

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)

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SECtion 3: final advErSE aCtionS/ConviCtionS
final advErSE aCtionS that MuSt bE rEPortEd
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.

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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.

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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

D

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)

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SECtion 3: final advErSE aCtionS/ConviCtionS (Continued)
final advErSE hiStory

1. Have you, under any current or former name or business identity, ever had a final adverse 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 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 action documentation and resolution.

datE

taKEn by

rESolution

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final advErSE aCtion

D

CMS-855I (07/11)

13

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 and Indian Health Facility enrolling with Trailblazers Health Enterprises?
Yes

No

Identify the type of organizational structure of this provider/supplier (Check one)
Corporation

Limited Liability Company

Partnership

Sole Proprietor

Other (Specify): ____________

Proprietary

Non-Profit

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

final advErSE hiStory
1. Has your organization, under any current or former name or business identity, ever had any of the
final adverse actions listed on page 12 of this application imposed against it?

R

YES–Continue Below NO–Skip to Section 4B

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

D

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

final advErSE 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 Authorized Agreement) to facilitate that reassignment.

CMS-855I (07/11)

14

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.
Medicare Identification Number
(if issued)

National Provider Identifier

b) Name of Group/Organization

Medicare Identification Number
(if issued)

National Provider Identifier

c) Name of Group/Organization

Medicare Identification Number
(if issued)

National Provider Identifier

d) Name of Group/Organization

e) Name of Group/Organization

C. Practice location information

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a) Name of Group/Organization

Medicare Identification Number
(if issued)

National Provider Identifier

Medicare Identification Number
(if issued)

National Provider Identifier

R

• If you completed Section 4A, complete Section 4C through Section 17 for your business.

• All locations disclosed on claims forms should be identified in this section as practice locations.

D

• Complete this section for each of your practice locations where you render services to Medicare
beneficiaries.

However, you should only report those practice locations within the jurisdiction of the Medicare
fee-for-service contractor to which you will submit this application. If you render services in a hospital
and/or other health care facility, furnish the name and address of that hospital or facility.
• Each practice location must be a specific street address as recorded by the United States Postal
Service. Do not report a P.O. Box.

• If you only render services in patients’ homes (house calls), you may supply your home address in this
section if you do not have an office. In Section 4H, explain that this address is for administrative
purposes only and that all services are rendered in patients’ homes.
• If you render services in a retirement or assisted living community, complete this section with the
names, telephone numbers and addresses of those communities.
If you have a CLIA number and/or FDA/Radiology Certification Number for this practice location,
provide that information and submit a copy of the most current CLIA and FDA certification for each
practice location reported.

CMS-855I (07/11)

15

SECtion 4: PraCtiCE loCation inforMation (Continued)
If you or your organization sees patients in more than one practice location, copy and complete this
Section 4C for each location.
ChECK onE
datE

ChangE

add

dElEtE

(mm/dd/yyyy)

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
if you are enrolling for the first time, or if you are adding a new practice location, the date you
provide should be the date you saw your first Medicare patient at this location.
Practice Location Name (“Doing Business As” name if different from Legal Business Name)

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Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Street Address Line 2 (Suite, Room, etc.)

City/Town

State

Telephone Number

Fax Number (if applicable)

E-mail Address (if applicable)

NPI

R

Medicare Identification Number (if issued)

ZIP Code + 4

D

Date you saw your first Medicare patient at this practice location (mm/dd/yyyy)

Is this practice location a:

Private practice office setting
Hospital

CLIA Number for this location (if applicable)

CMS-855I (07/11)

Retirement/assisted living community
Other health care facility
(Specify):___________________________________
FDA/Radiology (Mammography) Certification Number for
this location (if issued)

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SECtion 4: PraCtiCE loCation inforMation (Continued)
d. rendering Services in Patients’ homes

List the city/town, State, and ZIP code for all locations where health care services are rendered in patients’
homes. If you provide health care services in more than one State and those States are serviced by different
Medicare fee-for-service contractors, complete a separate enrollment application (CMS-855I) for each
Medicare fee-for-service contractor’s jurisdiction.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
ChECK onE
datE

ChangE

add

dElEtE

(mm/dd/yyyy)

initial rEPorting and/or additionS

If you are reporting or adding an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.
Entire State of __________________________

StatE

ZiP CodE

dElEtionS

D

R

City/town

AF
T

If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.

If you are deleting an entire State, it is not necessary to report each city/town. Simply check the box below
and specify the State.
Entire State of __________________________

If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
City/town

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StatE

ZiP CodE

17

SECtion 4: PraCtiCE loCation inforMation (Continued)
E. where do you want remittance notices or Special Payments Sent?

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
ChECK onE
datE

ChangE

add

dElEtE

(mm/dd/yyyy)

Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT,
the “Special Payments” address will indicate where all other payment information (e.g., remittance notices,
special payments) are sent.
“Special Payments” address is the same as the practice location (only one address is listed in
Section 4C). Skip to Section 4F.

“Special Payments” address is different than that listed in Section 4C, or multiple locations are listed.
Provide address below.

AF
T

Furnish the address where remittance notices and special payments should be sent for services rendered at
the practice location(s) in Section 4C. Note that payments will be made in your name; if an entity is listed
in Section 4A of this application, payments will be made in the organization’s name.
“Special Payment” Address Line 1 (PO Box or Street Name and Number)

“Special Payment” Address Line 2 (Suite, Room, etc.)

State

ZIP Code + 4

R

City/Town

D

f. Employer id number information
notE: If you are a sole proprietor and you want Medicare payments to be reported under your EIN, list it

below. Unless indicated in this section, payments will be made to your SSN. You cannot use both an SSN
and EIN. You can only use one EIN to bill Medicare.
To qualify for this payment arrangement, you:
• Must be a sole proprietor,
• Cannot reassign all of your Medicare payments, and,
• Want your payments to be made to your EIN. Furnish IRS documentation showing your EIN.
Employer Identification Number (EIN)

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SECtion 4: PraCtiCE loCation inforMation (Continued)
g. where do you Keep Patients’ Medical records?

If the patients’ medical records are stored at a location other than the location shown in Section 4C,
complete this section with the name and address of the storage location. This includes both current and
former patients’ records.

Post Office Boxes and drop boxes are not acceptable as physical addresses where patients’ records
are maintained. The records must be your records, not those of another supplier. If this section is not
completed, you are indicating that all records are stored at the practice locations reported in Section 4C.

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
first Medical record Storage facility (for current and former patients)
ChECK onE
datE

ChangE

add

dElEtE

(mm/dd/yyyy)

AF
T

Storage Facility Address Line 1 (Street Name and Number)

Storage Facility Address Line 2 (Suite, Room, etc.)

City/Town

State

ZIP Code + 4

Second Medical record Storage facility (for current and former patients)
ChECK onE
(mm/dd/yyyy)

add

dElEtE

R

datE

ChangE

D

Storage Facility Address Line 1 (Street Name and Number)

Storage Facility Address Line 2 (Suite, Room, etc.)

City/Town

State

ZIP Code + 4

h. unique Circumstances

Explain any unique circumstances concerning your practice locations or the method by which you render
health care services (e.g., you only render services in patients’ homes [house calls only]).

SECtion 5: for futurE uSE (thiS SECtion not aPPliCablE)

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SECtion 6: individualS having Managing Control
This section captures information about all managing employees. A managing employee means a general
manager, business manager, administrator, director, or other individual who exercises operational or
managerial control over, or who directly or indirectly conducts, the day-to-day operations of the supplier,
either under contract or through some other arrangement, regardless of whether the individual is a W-2
employee of the supplier.
All managing employees at any of your practice locations shown in Section 4 must be reported in this
section. If there is more than one managing employee, copy and complete this section as needed.

a. Managing Employee identifying information

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
ChECK onE
datE

ChangE

add

dElEtE

(mm/dd/yyyy)

Middle Initial Last Name

Jr., Sr., etc. Title

AF
T

First Name

Social Security Number (Required) Date of Birth (mm/dd/yyyy)

Medicare Identification Number (if issued)

Place of Birth (State)

NPI (if issued)

R

What is the effective date this individual acquired managing control of the provider identified in Section 2A
of this application? (mm/dd/yyyy)

b. final adverse history

D

Complete this section for the individual reported in Section 6A above. If you are changing or adding
information, check the “change” box, furnish the effective date, and complete the appropriate fields in
this section.
Change

Effective Date:______________________
1. Has this individual in Section 6A above, under any current or former name or business identity, ever
had a final adverse action listed on page 12 of this application imposed against him/her?

YES–Continue Below NO–Skip to Section 8
2. If yes, report each final adverse 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 action documentation and resolution.

final advErSE aCtion

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datE

taKEn by

rESolution

20

SECtion 7: for futurE uSE (thiS SECtion not aPPliCablE)
SECtion 8: billing agEnCy inforMation
A billing agency is a company or individual that you contract with to prepare and submit your claims. If
you use a billing agency, you are responsible for the claims submitted on your behalf.
ChECK hErE

if this section does not apply and skip to Section 13.

If you are changing, adding, or deleting information, check the applicable box and furnish the
effective date.
ChECK onE
datE

ChangE

add

dElEtE

(mm/dd/yyyy)

billing agency name and address

Complete the appropriate fields in this section.
If Individual, Billing Agent Date of Birth
(mm/dd/yyyy)

AF
T

Legal Business Name (as Reported to the Internal Revenue Service)

“Doing Business As” Name (if applicable)

Tax ID Number or Social Security Number (required)

Billing Agency Address Line 1 (Street Name and Number)

R

Billing Agency Address Line 2 (Suite, Room, etc.)

D

City/Town

Telephone Number

Fax Number (if applicable)

State

ZIP Code + 4

E-mail Address (if applicable)

SECtion 9: for futurE uSE (thiS SECtion not aPPliCablE)
SECtion 10: for futurE uSE (thiS SECtion not aPPliCablE)
SECtion 11: for futurE uSE (thiS SECtion not aPPliCablE)
SECtion 12: for futurE uSE (thiS SECtion not aPPliCablE)

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SECtion 13: ContaCt PErSon
This section captures information regarding the person you would like for us to contact regarding this
application. If no one is listed below, we will contact you directly.
First Name

Middle Initial

Last Name

Telephone Number

Fax Number (if applicable)

Jr., Sr., etc.

E-mail Address (if applicable)

Address Line 1 (Street Name and Number)

Address Line 2 (Suite, Room, etc.)

State

ZIP Code + 4

D

R

AF
T

City/Town

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SECtion 14: PEnaltiES for falSifying inforMation
this section explains the penalties for deliberately furnishing false information in this application
to gain or maintain enrollment in the Medicare program.

1. 1.18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within
the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies,
conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious, or
fraudulent statements or representations, or makes any false writing or document knowing the same to
contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines
of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject
to fines of up to $500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice
the gross gain derived by the offender if it is greater than the amount specifically authorized by the
sentencing statute.
2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual
who, “knowingly and willfully,” makes or causes to be made any false statement or representation of
a material fact in any application for any benefit or payment under a Federal health care program. The
offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.

AF
T

3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who:
a) knowingly presents, or causes to be presented, to an officer or any employee of the United

States Government a false or fraudulent claim for payment or approval;
b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or
fraudulent claim paid or approved by the Government; or

c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.

The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of
damages sustained by the Government

D

R

4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including
an organization, agency or other entity) that knowingly presents or causes to be presented to an officer,
employee, or agent of the United States, or of any department or agency thereof, or of any State
agency…a claim…that the Secretary determines is for a medical or other item or service that the
person knows or should know:
a) was not provided as claimed; and/or
b) the claim is false or fraudulent.
This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an
assessment of up to three times the amount claimed, and exclusion from participation in the Medicare
program and State health care programs.

5. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health
care benefit program who knowingly and willfully falsifies, conceals or covers up by any trick,
scheme, or device a material fact; or makes any materially false, fictitious, or fraudulent statements
or representations, or makes or uses any materially false fictitious, or fraudulent statement or entry, in
connection with the delivery of or payment for health care benefits, items or services. The individual
shall be fined or imprisoned up to 5 years or both.

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SECtion 14: PEnaltiES for falSifying inforMation (Continued)
6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute,
or attempt, to executive a scheme or artifice to defraud any health care benefit program, or to obtain,
by means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by or under the control of any, health care benefit program in connection with the delivery of or
payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up to 10
years or both. If the violation results in serious bodily injury, an individual will be fined or imprisoned up
to 20 years, or both. If the violation results in death, the individual shall be fined or imprisoned for any
term of years or for life, or both.
7. The government may assert common law claims such as “common law fraud,” “money paid by
mistake,” and “unjust enrichment.”

D

R

AF
T

Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the

unjust profit.

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SECtion 15: CErtifiCation StatEMEnt (Continued)
As an individual practitioner, you are the only person who can sign this application. The authority to sign
the application on your behalf may not be delegated to any other person.
The Certification Statement contains certain standards that must be met for initial and continuous
enrollment in the Medicare program. Review these requirements carefully.

By signing the Certification Statement, you agree to adhere to all of the requirements listed therein and
acknowledge that you may be denied entry to or revoked from the Medicare program if any requirements
are not met.

Certification Statement

D

R

AF
T

You MUST sign and date the certification statement below in order to be enrolled in the Medicare program.
In doing so, you are attesting to meeting and maintaining the Medicare requirements stated below.
I, the undersigned, certify to the following:
1. I have read the contents of this application, and the information contained herein is true, correct, and
complete. If I become aware that any information in this application is not true, correct, or complete, I
agree to notify the Medicare fee-for-service contractor of this fact in accordance with the time frames
established in 42 CFR § 424.516.
2. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the
Medicare contractor of a change in ownership, practice location and/or Final Adverse Action within 30
days of the reportable event. In addition, I agree to notify the Medicare contractor of any other changes to
the information to this form within 90 days of the effective date of change. I understand that any change
to my status as an individual practitioner may require the submission of a new application. I understand
that any change in business structure of this supplier may require the submission of a new application.
3. I have read and understand the Penalties for Falsifying Information, as printed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information
contained in this application or contained in any communication supplying information to Medicare,
or any deliberate alteration of any text on this application form, may be punished by criminal, civil,
or administrative penalties including, but not limited to, the denial or revocation of Medicare billing
privileges, and/or the imposition of fines, civil damages, and/or imprisonment.
4. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to the
organization listed in Section 4A of this application. The Medicare laws, regulations, and program
instructions are available through the fee-for-service contractor. I understand that payment of a claim
by Medicare is conditioned upon the claim and the underlying transaction complying with such laws,
regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and
the Stark law), and on the supplier’s compliance with all applicable conditions of participation
in Medicare.
5. Neither I, nor any managing employee listed on this application, is currently sanctioned, suspended,
debarred, or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or any
other Federal program, or is otherwise prohibited from providing services to Medicare or other Federal
program beneficiaries.
6. I agree that any existing or future overpayment made to me (or to the organization listed in Section 4A
of this application) by the Medicare program may be recouped by Medicare through the withholding of
future payments.
7. I understand that the Medicare identification number issued to me can only be used by me or by a
provider or supplier to whom I have reassigned my benefits under current Medicare regulations, when
billing for services rendered by me.
8. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by
Medicare, and will not submit claims with deliberate ignorance or reckless disregard of their truth
or falsity.
9. I further certify that I am the individual practitioner who is applying for Medicare billing privileges.
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SECtion 15: CErtifiCation StatEMEnt (Continued)
First Name

Middle Initial Last Name

Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)

M.D., D.O., etc.

Date Signed (mm/dd/yyyy)

all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed not original will
not be processed. Stamped, faxed or copied signatures will not be accepted.

SECtion 16: for futurE uSE (thiS SECtion not aPPliCablE)
SECtion 17: SuPPorting doCuMEntS

AF
T

This section lists the documents that, if applicable, must be submitted with this enrollment
application. For changes, only submit documents that are applicable to the change requested. The
fee-for-service contractor may request, at any time during the enrollment process, documentation to
support or validate information reported on the application. In addition, the Medicare fee-for-service
contractor may also request documents from you, other than those identified in this section 17, as are
necessary to bill Medicare.
Mandatory for all ProvidEr/SuPPliEr tyPES

R

Completed Form CMS-588, for Electronic Funds Transfer Authorization Agreement.
notE: If a supplier already receives payments electronically and is not making a change to his/her
banking information, the CMS-588 is not required. (Moreover, physicians and non-physician
practitioners who are reassigning all of their payments to another entity are not required to submit the
CMS-588.)
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business
Name (e.g., IRS form CP 575) provided in Section 2. (notE: This information is needed if the applicant
is enrolling their professional corporation, professional association, or limited liability corporation with
this application or enrolling as a sole proprietor using an Employer Identification Number.)

Mandatory, if aPPliCablE

D

Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit.
Copy(s) of all final adverse action documentation (e.g., notifications, resolutions, and reinstatement

letters).

Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.
Completed Form CMS-855R, Individual Reassignment of Medicare Benefits.
Statement in writing from the bank. If Medicare payment due a supplier of services is being sent to a
bank (or similar financial institution) where the supplier has a lending relationship (that is, any type of
loan), then the supplier must provide a statement in writing from the bank (which must be in the loan
agreement) that the bank has agreed to waive its right of offset for Medicare receivables.
Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically
classified as a Disregarded Entity (e.g., Form 8832). (notE: A disregarded entity is an eligible entity
that is treated as an entity not separate from its single owner for income tax purposes. A “disregarded
entity” is treated as separate from its owner.)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete
this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.
do not Mail aPPliCationS to thiS addrESS. Mailing your application to this address will significantly delay application processing.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEdiCarE SuPPliEr EnrollMEnt aPPliCation PrivaCy aCt StatEMEnt

The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information requested on this form
by sections 1124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42 U.S.C.
§§ 1320a-3(a)(1), 1320a-7, 1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt Collection
Improvement Act [31 U.S.C. § 7701(c)].
The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations
to enroll in the Medicare program as suppliers of goods and services to Medicare beneficiaries and to assist in the
administration of the Medicare program. This information will also be used to ensure that no payments will be made
to providers who are excluded from participation in the Medicare program. All information on this form is required,
with the exception of those sections marked as “optional” on the form. Without this information, the ability to make
payments will be delayed or denied.
The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
The information in this application will be disclosed according to the routine uses described below.

D

R

AF
T

Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
2. A congressional office from the record of an individual health care provider in response to an inquiry from the
congressional office at the written request of that individual health care practitioner;
3. The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
4. Peer Review Organizations in connection with the review of claims, or in connection with studies or other review
activities, conducted pursuant to Part B of Title XVIII of the Social Security Act;
5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States
Government is a party to litigation and the use of the information is compatible with the purpose for which the
agency collected the information;
6. To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which
criminal penalties are attached;
7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when
the National Plan and Provider Enumeration System is unable to establish identity after matching contractor
submitted data to the data extract provided by the AMA;
8. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of
disease or disability, or to the restoration or maintenance of health;
9. Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers of
medical services or to detect fraud or abuse;
10. State Licensing Boards for review of unethical practices or non-professional conduct;
11. States for the purpose of administration of health care programs; and/or
12. Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health
care groups providing health care claims processing, when a link to Medicare or Medicaid claims is established,
and data are used solely to process supplier’s health care claims.
The supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503)

amended the Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through

computer matching.

Protection of Proprietary information
Privileged or confidential commercial or financial information collected in this form is protected from public
disclosure by Federal law 5 U.S.C. § 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal information
If any information within this application (or attachments thereto) constitutes a trade secret or privileged or
confidential information (as such terms are interpreted under the Freedom of Information Act and applicable case
law), or is of a highly sensitive personal nature such that disclosure would constitute a clearly unwarranted invasion
of the personal privacy of one or more persons, then such information will be protected from release by CMS under
5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.
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