CMS-855B Enrollment Opioid Treatment Program

Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)

CMS-855B - Enrollment Application

Medicare Enrollment Application (Initial Enrollment)

OMB: 0938-1377

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MEDICARE ENROLLMENT APPLICATION
Clinics/Group Practices and Other Suppliers

CMS-855B
Go to pages 1–2 to determine if you are completing the correct application.
Go to page 3 for information on where to mail this completed application.
Go to section 12 for a list of supporting documentation to be submitted with this
application.
To review your current Medicare enrollment record, go to:
PECOS.cms.hhs.gov

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-1377
Expires: XX/XXXX

WHO SHOULD SUBMIT THIS APPLICATION
Clinics, group practices, and other suppliers must complete this application to enroll in the Medicare program
and receive a Medicare billing number.
Clinics, group practices, and other suppliers 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 CMS-855B enrollment application. Be sure you are using the most current version.
For additional information regarding the Medicare enrollment process, including Internet-based PECOS and to
get the current version of the CMS-855B, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.
NOTE: Applicants using this application require a Type 2 NPI. See below for more information.
NOTE: For the purposes of this application, the word “supplier” is used universally and includes any providers
or suppliers who are required to complete the CMS-855B application.
Complete and submit this application if you are an organization/group or other supplier that plans to bill
Medicare and you are:
• Enrolling in the Medicare program for the first time with this Medicare Administrative Contractor (MAC)
under this tax identification number.
• Currently enrolled in Medicare but have a new tax identification number. If you are reporting a change to
your current Medicare enrollment to your tax identification number, you must complete a new application.
• Currently enrolled in Medicare and need to enroll in another Medicare Administrative Contractor’s (MAC’s)
jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another MAC).
• Revalidating your Medicare enrollment. CMS may require you to submit or update your enrollment
information. The MAC will notify you when it is time for you to revalidate your enrollment information. Do
not submit a revalidation application until you have been contacted by your MAC.
• Previously enrolled in Medicare and you need to reactivate your Medicare billing number to resume
billing. Prior to being reactivated, you must meet all current requirements for your supplier type before
reactivation may occur.
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have
added or changed a practice location). Changes must be reported in accordance with the timeframes
established in 42 C.F.R. section 424.516. (IDTF changes of information must be reported in accordance with
42 C.F.R. section 410.33.)
• A hospital, hospital department, or other medical practice or clinic that may bill for Medicare Part A services
but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other
entities that will bill Medicare Part B.
• A certified Medicare Part B provider (i.e. Ambulatory Surgery Center, Portable X-ray Supplier) intending
to report a CHOW. A CHOW typically occurs when a Medicare provider has been purchased (or leased) by
another organization. The CHOW results in the transfer of the old owner’s Medicare Identification Number
and provider agreement (including any outstanding Medicare debt of the old owner) to the new owner.
The regulatory citation for CHOWs can be found at 42 C.F.R. 489.18. If the purchaser (or lessee) elects not
to accept a transfer of the provider agreement, then the old agreement should be terminated and the
purchaser or lessee is considered a new applicant and must initially enroll in Medicare.
• A medical practice, group/clinic or other supplier that will bill for Medicare Part B services (e.g., group
practices, clinics, independent laboratories, portable x-ray suppliers).
• Accepting a new reassignment of Medicare benefits, terminating a reassignment of Medicare benefits, or
making a change in reassignment of Medicare benefit information, between the organization/group and
an individual practitioner.
• Terminating an employer or individual relationship with an Independent Diagnostic Testing Facility (IDTF).
• Voluntary terminating your Medicare billing privileges. A supplier should voluntarily terminate its Medicare
enrollment when it:
• Will no longer be rendering services to Medicare patients, or
• Is planning to cease (or has ceased) operations.

CMS-855B (XX/XX)

BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATION
The Provider Transaction Access Number (PTAN), often referred to as a Medicare Supplier Number or Medicare
Billing Number, is a generic term for any number other than the National Provider Identifier (NPI) that is used
by a supplier to bill the Medicare program.
The NPI is the standard unique health identifier for health care providers and suppliers and is assigned by
the National Plan and Provider Enumeration System (NPPES). To enroll in Medicare, you must obtain an NPI
and furnish it on this application prior to enrolling in Medicare or when submitting a change to your existing
Medicare enrollment information. Applying for the NPI is a process separate from Medicare enrollment.
As a supplier, it is your responsibility to determine if you have “subparts.” A subpart is a component of an
organization (supplier) that furnishes healthcare and is not itself a legal entity. If you do have subparts, you
must determine if they should obtain their own unique NPIs. Before you complete this enrollment application,
you need to make those determinations and obtain NPI(s) accordingly. To obtain an NPI, you may apply online
at NPPES.cms.hhs.gov. For more information about NPI enumeration, visit
CMS.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand.
NOTE: The Legal Business Name (LBN) and Tax Identification Number (TIN) that you furnish in section 2A must
be the same LBN and TIN you used to obtain your NPI. Once this information is entered into PECOS from this
application, your LBN, TIN and NPI must match exactly in both PECOS and NPPES.
Organizational Health Care Providers (Entity Type 2): Organizational health care providers are eligible for
an Entity Type 2 NPI (Organizations). Organizational health care providers may have a single employee or
thousands of employees. Examples of organizational providers include hospitals, home health agencies,
groups/clinics, nursing homes, ambulance companies, health care provider corporations formed by groups/
individuals, and single member LLCs with an EIN, not individual health care providers.
Important: For NPI purposes, sole proprietors and sole proprietorships are considered to be “Type 1” providers.
Organizations (e.g., corporations, partnerships) are treated as “Type 2” entities. When reporting the NPI of a
sole proprietor on this application, therefore, the individual’s Type 1 NPI should be reported; for organizations,
the Type 2 NPI should be furnished.
To obtain an NPI, you may apply online at NPPES.cms.hhs.gov.

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION
All information on this form is required with the exception of those fields specifically marked as “optional.”
Any field marked as optional is not required to be completed nor does it need to be updated or reported as
a “change of information” as required in 42 C.F.R. section 424.516. However, it is highly recommended that if
reported, these fields be kept up-to-date.
•
•
•
•

This form must be typed. It may not be handwritten.
When necessary to report additional information, copy and complete the applicable section as needed.
Sign and date the certification statement(s) as appropriate.
When establishing a new reassignment, Section 15E must be signed by the individual practitioner and
Section 15B or 15D must be signed by a delegated/authorized official of the organization/group.
• When terminating a reassignment or making changes to reassignment information, either the delegated/
authorized official of the organization/group must sign Section 15B or 15D or the individual practitioner
must sign Section 15E. In the case of termination, reassigned claims for services rendered by the individual
will no longer be paid to the organization/group after the effective date of the termination.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your own records.

CMS-855B (XX/XX)

TIPS TO AVOID DELAYS IN YOUR ENROLLMENT
To avoid delays in the enrollment process, you should:
•
•
•
•
•

Complete all required sections, as shown in section 1.
Ensure that the legal business name shown in section 2 matches the name on the tax documents.
Ensure that the correspondence address shown in section 2 is the supplier’s address.
Enter your NPI(s) in the applicable section(s).
Include the Electronic Funds Transfer (EFT) Authorization Agreement (when applicable) with your
enrollment application with a voided check or bank letter.
• Sign and date section 15.
• Ensure all supporting documents are sent to your designated MAC.
• The supplier pays the required application fee (via PECOS.cms.hhs.gov/pecos/feePaymentWelcome.do)
upon initial enrollment, the addition of a new business location, and revalidation PRIOR to completing and
submitting this application to the MAC.

ADDITIONAL INFORMATION
• You may visit our website to learn more about the enrollment process via the Internet-Based Provider
Enrollment Chain and Ownership System (PECOS) at: CMS.gov/Medicare/Provider-Enrollment-andCertification. Also, all of the CMS-855 applications are located on the CMS webpage: CMS.gov/Medicare/
CMS-Forms/CMS-Forms/CMS-Forms-List. Simply enter “855” in the “Filter On:” box on this page and the
application forms will be displayed to choose from.
• The MAC may request additional documentation to support and validate information reported on this
application. You are responsible for providing this documentation within 30 days of the request per 42
C.F.R. section 424.525(a)(1) and (2).
• The 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.

ACRONYMS COMMONLY USED IN THIS APPLICATION
C.F.R.: Code of Federal Regulations
EFT: Electronic Funds Transfer
EIN: Employer Identification Number
IHS: Indian Health Service
IRS: Internal Revenue Service
LBN: Legal Business Name
LLC: Limited Liability Corporation
MAC: Medicare Administrative Contractor

NPI: National Provider Identifier
NPPES: National Plan and Provider Enumeration
System
OTP: Opioid Treatment Program
PTAN: Provider Transaction Access Number also
referred to as the Medicare Identification Number
SSN: Social Security Number
TIN: Tax Identification Number

DEFINITIONS
NOTE: For the purposes of this CMS-855B application, the following definitions apply:
• Add: You are adding additional enrollment information to your existing information (e.g. practice
locations).
• Change: You are replacing existing information with new information (e.g. billing agency, managing
employee) or updating existing information (e.g. change in suite #, telephone #).
• Remove: You are removing existing enrollment information.
• Reassignment of Medicare Benefits: Authorization by an individual practitioner to allow an eligible
organization/group to submit claims and receive payment for Medicare Part B services that the practitioner
has provided as a member of the organization/group. Such an eligible organization/group may be an
individual, a clinic/group practice or other health care organization.

WHERE TO MAIL YOUR APPLICATION
Send this completed application with original signatures and all required documentation to your designated
MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the
mailing address for your designated MAC, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.
CMS-855B (XX/XX)

SECTION 1: BASIC INFORMATION
A. REASON FOR SUBMITTING THIS APPLICATION
Check one box and complete the required sections of this application as indicated.
You are a new enrollee in Medicare

Complete all applicable sections
Ambulance suppliers must complete
Attachment 1
IDTF suppliers must complete Attachment 2
OTPs must complete Attachment 3

You are solely enrolling in Medicare to participate in
Medicaid or another health care program and will not bill
Medicare

Complete all applicable sections

You are enrolling with another Medicare Administrative
Contractor (MAC)

Complete all applicable sections
Ambulance suppliers must complete
Attachment 1
IDTF suppliers must complete Attachment 2
OTPs must complete Attachment 3

You are revalidating your Medicare enrollment

Complete all applicable sections
Ambulance suppliers must complete
Attachment 1
IDTF suppliers must complete Attachment 2
OTPs must complete Attachment 3

You are reactivating your Medicare enrollment

Complete all applicable sections
Ambulance suppliers must complete
Attachment 1
IDTF suppliers must complete Attachment 2
OTPs must complete Attachment 3

You are changing your Medicare information

Go to section 1B below

You are voluntarily terminating your Medicare enrollment
Effective date of termination (mm/dd/yyyy):

Section 1, 2A1, 2A3 (optional), 4B (optional),
13 (optional), and 15

Medicare Identification Number:

CMS-855B (XX/XX)

SECTION 1: BASIC INFORMATION (Continued)
B. WHAT INFORMATION IS CHANGING?
Check all that apply and complete the required sections.
NOTE: When reporting ANY information, sections 1, 2A1, 3, and 15 MUST always be completed in addition to
the information that is changing within the required section.
Changing Information

Required Sections

Business Identifying Information

1, 2A1, 3, 12, 13 (optional) and 15 and 6 for
the signer if that authorized or delegated
official has not been established for this
supplier

Final Adverse Legal Actions

1, 2A1, 3, 12, 13 (optional) and 15 and 6 for
the signer if that authorized or delegated
official has not been established for this
supplier

Medical Specialty Information

1, 2A, 2B, 3, 4, 12, 13 (optional), and 15 and 6
for the signer if that authorized or delegated
official has not been established for this
supplier

Supplier Specific Information

1, 2A1, 2A2-2A4, 2B–2F (as applicable), 3,
12,13 (optional), and 15 and 6 for the signer if
that authorized or delegated official has not
been established for this supplier

Reassignment of Benefits Information

1, 2A1, 2F, 3, 13 (optional) and 15 and 6 for
the signer if that authorized or delegated
official has not been established for this
supplier

Private Practice Business Information

1, 2A1, 4H, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier

Change of Ownership (Portable X-Ray Suppliers,
Ambulatory Surgical Centers and Opioid Treatment
Programs Only)

Complete all sections and provide a copy of
the sales agreement

Ownership Interest and/or Managing Control Information
(Organizations)

1, 2A1, 3, 5, 13, and 15, and 6 for the signer if
that authorized or delegated official has not
been established for this supplier

Ownership Interest and/or Managing Control Information
(Individuals)

1, 2A1, 3, 6, 13, and 15, and another 6 for the
signer if that authorized or delegated official
has not been established for this supplier

Managing Employee Information

1, 2A1, 3, 6, 12, 13 (optional), and 15 and 6
for the signer if that authorized or delegated
official has not been established for this
supplier

CMS-855B (XX/XX)

SECTION 1: BASIC INFORMATION (Continued)
Changing Information
Address Information
Correspondence Mailing Address
Medical Record Correspondence Mailing Address
Medicare Beneficiary Medical Records Storage Address
Practice Location Address

Required Sections
1, 2A1, 3, 12, 13 (optional) and 15 AND
sections 2A3, 2A4, 4A, 4B, 4C, and/or
4E as applicable for the address that is
being changed and 6 for the signer if that
authorized or delegated official has not been
established for this supplier

Remittance Notices/Special Payment Mailing Address
Base of Operations Address for Mobile or Portable
Suppliers (location of Business Office or Dispatcher/
Scheduler)
Billing Agency Information

1, 2A1, 3, 8, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier

Authorized Official(s) and/or Delegated Official(s)

1, 2A1, 3, 13, 15A1 (if you are an Authorized
Official) or 15B1 (if you are a delegated
official), and another 6 for the signer if that
authorized or delegated official has not been
established for this supplier

Any other information not specified above

1, 2A1, 3, 12 (if applicable), 13 (optional) and
15 and the applicable section or sub-section
that is changing and 6 for the signer if that
authorized or delegated official has not been
established for this supplier

ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS (ONLY)
Changing Information
Ambulance Supplier Transport Type

Required Sections
1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 1(A)

Geographic Area

1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 1(B)

State License Information

1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 1(C)

Vehicle Information

1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 1(D)

CMS-855B (XX/XX)

SECTION 1: BASIC INFORMATION (Continued)
ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (ONLY)
Changing Information
CPT-4 and HCPCS Codes

Required Sections
1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 2(B)

Interpreting Physician Information

1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 2(C)

Personnel (Technicians) Who Perform Tests

1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 2(D)

Supervising Physicians

1, 2A, 3, 12, 13 (optional) and 15 and 6 for the
signer if that authorized or delegated official
has not been established for this supplier
Attachment 2(E)

ATTACHMENT 3: OPIOID TREATMENT PROGRAMS (ONLY)
Changing Information
Opioid Treatment Program Personnel – Ordering Personnel
Identification

Required Sections
1, 2A1, 3, 12, 13 (optional) and 15 and 6 for
the signer if that authorized or delegated
official has not been established for this
supplier
Attachment 3A

Opioid Treatment Program Personnel – Dispensing
Personnel Identification

1, 2A1, 3, 12, 13 (optional) and 15 and 6 for
the signer if that authorized or delegated
official has not been established for this
supplier
Attachment 3B

CMS-855B (XX/XX)

SECTION 2: IDENTIFYING INFORMATION
A. SUPPLIER IDENTIFICATION INFORMATION
1. Business Information
Change Effective Date (mm/dd/yyyy):
Legal Business Name as Reported to the Internal Revenue Service
Medicare Identification Number (PTAN) (if issued)

Tax Identification Number (TIN)
National Provider Identifier (NPI)

Other Name (if applicable)

Type of Other Name (if applicable). Check box indicating Type of Other Name:
Former Legal Business Name
Doing Business As Name
Other (Describe):

IRS Business Designation
Identify how your business is registered with the IRS and NPPES. (NOTE: If your business is a Federal and/or
State government supplier, indicate “Non-Profit” below. In addition, government-owned entities do not need
to provide an IRS Form 501(c)(3)).
Proprietary
Non-Profit (Submit IRS Form 501(c)(3)
Disregarded Entity (Submit IRS Form 8832)
NOTE: If a checkbox identifying how the business is registered with the IRS is not completed, the supplier will
be defaulted to “Proprietary.”
Identify the business structure: (Check one)
Corporation

Federal and/or State Government Type:
Federal
State

Limited Liability Company
General Partnership

City

Limited Partnership

County

Sole Owner

City-County

Sole Proprietor

Hospital District

Other (Specify):

Is this supplier an Indian Health Service (IHS) Facility?......................................................................

Yes

2. License/Certification/Registration Information
Complete the appropriate subsection(s) below for your supplier type as you will report in section 2B. If no
subsection is associated with your supplier type, check the box stating the information is not applicable.

a. Active License Information
License Not Applicable
License Number

CMS-855B (XX/XX)

Effective Date (mm/dd/yyyy)

State Where Issued

SECTION 2: IDENTIFYING INFORMATION (Continued)
b. Active Certification Information
Complete the appropriate subsection(s) below for your supplier type as you will report in section 2B. If no
subsection is associated with your supplier type, check the box stating the information is not applicable. *If
you are certified by a national entity, put the word “all” in the “State Where Issued” data field.
Certification Not Applicable
Certification Number

Effective Date (mm/dd/yyyy)

State Where Issued*

Certifying Entity (Specialty Board, State, Other)

3. Correspondence Mailing Address
This is the address where correspondence will be sent to the supplier listed in section 2A1 by your designated
MAC. This address cannot be a billing agent or agency’s address or a medical management company address.
If you are reporting a change to your Correspondence Mailing Address, check the box below. This will replace
any current Correspondence Mailing Address on file.
Change Effective Date (mm/dd/yyyy):
Attention (optional)
Correspondence Mailing Address Line 1 (P.O. Box or Street Name and Number)
Correspondence Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number (if applicable)

State
Fax Number (if applicable)

ZIP Code + 4
E-mail Address (if applicable)

4. Medicare Beneficiary Medical Records
This is the address where the medical record correspondence will be sent to the supplier listed in section 2A1
by your designated MAC. This information would be used for any medical record review requests.
Check here if your Medical Record Correspondence Address should be mailed to your Correspondence
Address in section 2A3 (above) and skip this section.
If you are reporting a change to your Medical Record Correspondence Address, check the box below. This will
replace any current Medical Record Correspondence Address on file.
Change Effective Date (mm/dd/yyyy):
Attention (optional)
Medical Record Correspondence Mailing Address Line 1 (P.O. Box or Street Name and Number)
Medical Record Correspondence Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number (if applicable)

CMS-855B (XX/XX)

State
Fax Number (if applicable)

ZIP Code + 4
E-mail Address (if applicable)

SECTION 2: IDENTIFYING INFORMATION (Continued)
B. TYPE OF SUPPLIER
Check the appropriate box to identify the type of supplier you are enrolling as with Medicare. If you are more
than one type of supplier, submit a separate application for each type. If you change the type of service that
you provide (i.e., become a different supplier type), submit a new application.
Your organization must meet all Federal and State requirements for the type of supplier checked below.

Type of Supplier: (Check one only)
Ambulance Service Supplier
Ambulatory Surgical Center
Clinic/Group Practice
Home Infusion Therapy Supplier
Hospital Department(s)
Independent Clinical Laboratory
Independent Diagnostic Testing Facility
Intensive Cardiac Rehabilitation
Mammography Center

Mass Immunization (Roster Biller Only)
Occupational Therapy Group in Private Practice
Opioid Treatment Program
Pharmacy
Physical Therapy Group in Private Practice
Portable X-ray Supplier
Radiation Therapy Center
Other (Specify):

NOTE: Only use “other” checkbox if your supplier type is eligible to enroll and bill the Medicare program but
is not reflected in the list of suppliers. If you are unsure of your provider type or if you are eligible to enroll
contact your designated MAC before you submit this application.

C. HOSPITALS ONLY
This section should only be completed by hospitals that are currently enrolled or enrolling with a MAC (the
Part A Medicare contractor), and will be billing a MAC for Medicare Part B services, as follows:
• Hospitals requiring a Part B billing number to provide pathology services.
• Hospitals requiring a Medicare Part B billing number to provide purchased tests to other Medicare Part B
billers.
• If the hospital requires more than one departmental Part B billing number to bill for Part B practitioner
services, list each department needing a number.
If your organization is not a hospital, and believes it will need a Part B billing number, contact the designated
MAC to determine if this form should be submitted.
NOTE: Only complete this section if the clinic/hospital department is located within the hospital. If your
hospital is enrolling a clinic that is not located within the hospital, do not complete this section.
Check “Clinic/Group Practice” in section 2B and complete this entire application for the clinic/group practice.
1. Are you going to:
bill for the entire hospital with one billing number? (If yes, continue to section 2D.)
separately bill for each hospital department? (If yes, answer question 2.)
2. List the hospital departments for which you plan to bill separately:
DEPARTMENT

CMS-855B (XX/XX)

MEDICARE IDENTIFICATION NUMBER

NPI

SECTION 2: IDENTIFYING INFORMATION (Continued)
D. PHYSICAL THERAPY (PT) AND OCCUPATIONAL THERAPY (OT) GROUPS ONLY
1. Does this group ONLY render PT/OT services in patients’ homes?..................................................

Yes

2. Does this group maintain private office space?...............................................................................

Yes

3. Does this group own, lease, or rent its private office space?..........................................................

Yes

4. Is this private office space used exclusively for the group’s private practice?...............................

Yes

5. Does this group provide PT/OT services outside of its office and/or patients’ homes?.................

Yes

If you responded YES to questions 2, 3, or 4 above, you must have and attach a copy of any written agreement
that gives the group exclusive use of the office space for PT/OT services.

E. ACCREDITATION FOR AMBULATORY SURGICAL CENTERS (ASCs) ONLY
NOTE: Copy and complete this section if more than one accreditation needs to be reported.
Check one of the following and furnish any additional information as requested:
The enrolling ASC supplier is accredited.
The enrolling ASC applied for or is pending accreditation.
The enrolling ASC supplier is not accredited (includes exempt suppliers).
Name of Accrediting Organization
Effective Date of Current Accreditation (mm/dd/yyyy)

CMS-855B (XX/XX)

Expiration of Current Accreditation (mm/dd/yyyy)

SECTION 3: FINAL ADVERSE LEGAL ACTIONS
This section captures information regarding final adverse legal actions, such as convictions, exclusions, license
revocations and license suspensions. All applicable final adverse legal actions must be reported, regardless of
whether any records were expunged or any appeals are pending.
NOTE: To satisfy the reporting requirement, section 3 must be filled out in its entirety, and all applicable
attachments must be included.

A. FEDERAL AND STATE CONVICTIONS (Conviction as defined in 42 C.F.R. Section 1001.2)
WITHIN THE PRECEDING 10 YEARS
1. Any federal or state felony conviction(s) by the provider, supplier, or any owner, managing employee,
managing organization, officer or director of the provider or supplier.
2. Any crime, under Federal or State law, where an individual or entity has entered into participation in a
first offender, deferred adjudication or other program or arrangement where judgment of conviction
has been withheld, or the criminal conduct has been expunged or otherwise removed, or there is a posttrial motion or appeal pending, or the court has made a finding of guilt or accepted a plea of guilty or
nolo contendere.
3. 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.
4. Any misdemeanor conviction, under federal or state law, related to the theft, fraud, embezzlement,
breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health care
item or service.
5. Any misdemeanor conviction, under federal or state law, related to the unlawful manufacture,
distribution, prescription, or dispensing of a controlled substance.
6. Any misdemeanor conviction, under federal or state law, related to the interference with or obstruction
of any investigation into any criminal offence described in 42 C.F.R. section 1001.101 or 1001.201.
7. Any misdemeanor conviction, under federal or State law, related to sexual abuse, sexual misconduct,
inappropriate physical contact of another, or child pornography.

B. EXCLUSIONS, REVOCATIONS OR SUSPENSIONS
1. Any current or past revocation or suspension of a medical license.
2. Any voluntary surrender of a medical license in lieu of further disciplinary action.
3. Any current or past revocation or suspension of accreditation.
4. Any current or past exclusion imposed by the U.S. Department of Health and Human Service’s Office of
Inspector General (OIG).
5. Any current or past debarment from participation in any Federal Executive Branch procurement or nonprocurement program.
6. Any other current or past federal sanctions (A penalty imposed by a federal governing body (e.g. Civil
Monetary Penalties (CMP)).
7. Any current or past Medicaid or any federal health care program exclusion, revocation, or termination of
any billing number.

CMS-855B (XX/XX)

SECTION 3: FINAL ADVERSE LEGAL ACTIONS (Continued)
C. FINAL ADVERSE LEGAL ACTION
1. Has your organization, under any current or former name or business identity, had a final adverse legal
action listed above imposed against it?
YES – continue below

NO – skip to section 4

2. If yes, report each final adverse legal action, when it occurred, and the federal or state agency or the
court/administrative body that imposed the action.
FINAL ADVERSE LEGAL ACTION

CMS-855B (XX/XX)

DATE

ACTION TAKEN BY

SECTION 4: PRACTICE LOCATION INFORMATION
INSTRUCTIONS
This section captures information about the physical location(s) where you currently provide health care
services. If you operate a mobile facility or portable unit, provide the address for the “Base of Operations,” as
well as vehicle information and the geographic area serviced by these facilities or units.

MOBILE FACILITY AND/OR PORTABLE UNIT
A “mobile facility” is generally a mobile home, trailer, or other large vehicle that has been converted,
equipped, and licensed to render health care services. These vehicles usually travel to local shopping centers or
community centers to see and treat patients inside the vehicle.
A “portable unit” is when the supplier transports medical equipment to a fixed location (e.g., physician’s
office, nursing home) to render services to the patient.
The most common types of mobile facilities/portable units are mobile IDTFs, portable X-ray suppliers, portable
mammography, and mobile clinics. Physicians and non-physician practitioners (e.g., nurse practitioners,
physician assistants) who perform services at multiple locations (e.g., house calls, assisted living facilities) are
not considered to be mobile facilities/portable units.

A. PRACTICE LOCATION INFORMATION
Complete this section for each of your practice locations where you render services to Medicare beneficiaries,
including any distant site(s) where you render telehealth services. This includes all locations you will disclose
on claims forms for reimbursement. If you have and see patients at more than one private practice location or
health care facility, copy and complete this section for each location.
All reported practice location addresses must be a specific street address as recorded by the United States
Postal Service. Your practice location must be the physical location where you render services to Medicare
beneficiaries. Your practice location address cannot be a Post Office (P.O.) Box.
If you render services in a hospital, retirement or assisted living community, and/or other health care facilities,
furnish the name, address and telephone number for those facilities.
If you only render services in patients’ homes (house calls only), you may supply your home address in this
section if you do not have a separate office. In section 4D3 explain that this address is for administrative
purposes only and that all services are rendered in patients’ homes. You must then also complete section 4D1
as appropriate.
Only report those practice locations that are within the jurisdiction of the designated MAC to which you
will be submitting this application. If you have to report practice locations outside the jurisdiction of
the designated MAC to which you are submitting this application you must submit a separate CMS-855B
Enrollment Application to the MAC that has jurisdiction for those locations. 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.

CMS-855B (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
A. PRACTICE LOCATION INFORMATION
If you are changing information about a currently reported practice location or adding or removing practice
location information, check the applicable box, furnish the effective date, and complete the appropriate fields
in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Practice Location Name (“Doing Business As” Name, if applicable)
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)
Practice Location Street Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Telephone Number (if applicable)

Fax Number (if applicable)

Medicare Identification Number for this location – PTAN (if issued)
Is this your primary practice location?
Yes
No

ZIP Code + 4
E-mail Address (if applicable)

National Provider Identifier (NPI)

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

Is your private practice location reported above located in a:
Ambulatory Surgical Center
Business Office for Administrative/Telehealth Use Only
Group Practice Office/Clinic
Home Office for Administrative/Telehealth Use Only
Hospital or Hospital Department
Indian Health Services (IHS) or Tribal Facility Community
Retirement or Assisted Living
Skilled Nursing Facility or Other Nursing Facility
Other Health Care Facility (Specify):
CLIA Number for this location (if applicable)

Attach a copy of the most current CLIA certifications for each practice location(s) reported on this application.
FDA/Radiology (Mammography) Certification Number for this location (if issued)

Attach a copy of the most current FDA certifications for each practice location(s) reported on this application.

CMS-855B (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
B. REMITTANCE NOTICES/SPECIAL PAYMENTS MAILING ADDRESS
Furnish an address where remittance notices and special payments should be sent for services rendered at
the practice location(s) reported in section 4A. Please note that payments will be made in your name or, if a
business is reported in section 4A, payments will be made in the name of the business.
Medicare will issue all routine payments via electronic funds transfer (EFT). Since payments will be made by
EFT, the special payments address below should indicate where all other payment information (e.g., remittance
notices, non-routine special payments) should be sent.
Check here if your Remittance Notice/Special Payments should be mailed to your Primary Practice Location
Address in section 4A above and skip this section, OR
Check here if your Remittance Notice/Special Payments should be mailed to your Correspondence Address in
section 2A3 and skip this section.
If you are reporting a change to your Remittance Notice/Special Payments Mailing Address, check the box
below and furnish the effective date.
Change Effective Date (mm/dd/yyyy):
Special Payments Address Line 1 (P.O. Box or Street Name and Number)
Special Payments Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

ZIP Code + 4

C. MEDICARE BENEFICIARY MEDICAL RECORDS STORAGE ADDRESS
If your Medicare beneficiaries’ medical records are stored at a location other than the Practice Location
Address shown in section 4A complete this section with the name and address of the storage location. This
includes the records for both current and former Medicare beneficiaries.
Post office boxes and drop boxes are not acceptable as a physical address where Medicare beneficiaries’
records are maintained. The records must be your records and not the records of another practitioner. For
IDTFs and mobile facilities/portable units, the patients’ medical records must be under the supplier’s control.
If all records are stored at the Practice Location reported in section 4A, check the box below and skip this
section.
Records are stored at the Practice Location reported in section 4A.
If you are adding or removing a storage location, check the applicable box below and furnish the effective
date.
Add Remove Effective Date (mm/dd/yyyy):

1. Paper Storage
Name of Storage Facility
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

CMS-855B (XX/XX)

State

ZIP Code + 4

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
2. Electronic Storage
Do you store your patient medical records electronically?.............................................................

YES

If yes, complete all fields below.
Legal Business Name as reported to the Internal Revenue Service

Tax Identification Number (TIN)

Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

CMS-855B (XX/XX)

State

ZIP Code + 4

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
D. RENDERING SERVICES IN PATIENTS’ HOMES
List the city/town, county, state/territory, or ZIP code for all locations where you render health care services in
patients’ homes or, if previously reported, where you no longer render health care services in patients’ homes.
If you provide health care services in more than one state/territory and those states/territories are serviced by
different MACs, complete a separate CMS-855B enrollment application for each MAC’s jurisdiction.

1. Initial Reporting and/or Additions
If you are reporting or adding an entire state/territory, check the box below and specify the state/territory.
Entire State/Territory of __________________________
If services are only provided in selected cities/towns or counties, provide the locations below. Only list ZIP codes
if you are not servicing the entire city/town or county.
CITY/TOWN

COUNTY

STATE/ TERRITORY

ZIP CODE

2. Deletions
If you are deleting an entire state/territory, check the box below and specify the state/territory.
Entire State/Territory of __________________________
If services are no longer provided in selected cities/towns or counties, provide the locations below. Only list ZIP
codes if you are not deleting service in the entire city/town or county.
CITY/TOWN

COUNTY

STATE/ TERRITORY

ZIP CODE

3. Comments/Special Circumstances
Explain any unique circumstances concerning your practice location(s) or the method by which you render
health care services (e.g., practice on certain days of the week).

CMS-855B (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
E. BASE OF OPERATIONS ADDRESS FOR MOBILE OR PORTABLE SUPPLIERS (LOCATION OF
BUSINESS OFFICE OR DISPATCHER/SCHEDULER)
The base of operations is the location from where personnel are dispatched, where mobile/portable
equipment is stored, and when applicable, where vehicles are parked when not in use.
NOTE: When necessary to report more than one base of operations, copy and complete this section for each
base of operations.
If you are changing information about currently reported information, check the applicable box, furnish the
effective date, and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Check here and skip to section 4F if the “Base of Operations” address is the same as the “Practice Location”
listed in section 4A.
Base of Operations Street Address Line 1 (Street Name and Number)
Base of Operations Street Address Line 2 (Suite, Room, etc.)
City/Town

State

Telephone Number (if applicable)

Fax Number (if applicable)

ZIP Code + 4
E-mail Address (if applicable)

F. VEHICLE INFORMATION
If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish
the following vehicle information below. Do not provide information about vehicles that are used only to
transport medical equipment (e.g., when the equipment is transported in a van but is used in a fixed setting,
such as a doctor’s office) or ambulance vehicles. If more than four vehicles are used, copy and complete this
section as needed.
For each vehicle, submit a copy of all health care related permits/licenses/registrations.
If you are adding or removing information, check the applicable box, furnish the effective date, and complete
the appropriate fields in this section.

CHECK ONE FOR EACH VEHICLE
ADD

TYPE OF VEHICLE
(van, mobile home, trailer, etc.)

VEHICLE
IDENTIFICATION NUMBER

REMOVE

Effective Date (mm/dd/yyyy):

ADD

REMOVE

Effective Date (mm/dd/yyyy):

ADD

REMOVE

Effective Date (mm/dd/yyyy):

ADD

REMOVE

Effective Date (mm/dd/yyyy):

CMS-855B (XX/XX)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
G. GEOGRAPHIC LOCATION FOR MOBILE OR PORTABLE SUPPLIERS WHERE THE BASE OF
OPERATIONS AND/OR VEHICLE RENDERS SERVICES
Provide the city/town, county, state/territory, and zip code for all locations where mobile and/or portable
services are rendered.
NOTE: If you provide mobile or portable health care services in more than one state/territory and those states/
territories are serviced by different MACs, complete a separate CMS-855B enrollment application for each
MAC’s jurisdiction.

COUNTY

STATE/ TERRITORY

ZIP CODE

CMS-855B (XX/XX)

COUNTY

STATE/ TERRITORY

ZIP CODE

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
H. REASSIGNMENT OF BENEFITS INFORMATION
Complete this section if you are an organization/group accepting a new reassignment of Medicare benefits
from an individual practitioner, terminating a currently established reassignment of benefits between your
organization/group and an individual practitioner, or making a change in reassignment of Medicare benefit
information, between your organization/group and an individual practitioner.
The individual practitioner or delegated/authorized official of the organization/group, by his/her signature,
agrees to notify the Medicare Administrative Contractor (MAC) of any future changes to this reassignment in
accordance with 42 C.F.R. section 424.516(d)(2).
Both the individual practitioner and the eligible organization/group must be currently enrolled (or
concurrently enrolling via submission of the CMS-855B for the eligible organization/group and the CMS-855I
for the individual practitioner) in the Medicare program before the reassignment can take effect.
If the organization/group is accepting a reassignment of benefits from more than one practitioner, copy and
complete this page.

1. Individual Practitioner Reassigning Benefits Identification
Provide the information below for the individual practitioner who will be reassigning his/her benefits to the
organization/group in section 2A1, or who will be terminating a reassignment. If the practitioner’s initial
enrollment application is being submitted concurrently with this application, write “pending” in the Medicare
identification number block.
Add Terminate Effective Date (mm/dd/yyyy):
First Name (Print)

Middle Initial

Last Name

Social Security Number (SSN)

Medicare Identification Number (PTAN) (if issued)

Jr., Sr., M.D., etc.
National Provider Identifier (NPI)

2. Primary Practice Location(s) (Optional)
a. Primary Practice Location
Identify the primary practice location of the organization/group where the individual practitioner will render
in-person services most of the time. This practice location must be currently enrolled or enrolling in Medicare.
If you are changing information about a currently reported primary practice location or adding or removing
primary practice location information, check the applicable box, furnish the effective date, and complete the
appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)
Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Medicare Identification Number for this location – PTAN (if issued)

CMS-855B (XX/XX)

ZIP Code + 4
National Provider Identifier (NPI)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
b. Secondary Practice Location
Identify a secondary practice location of the organization/group where the individual practitioner will render
in-person services most of the time. This practice location must be currently enrolled or enrolling in Medicare.
If you are changing information about a currently reported additional practice location or adding or removing
an additional practice location information, check the applicable box, furnish the effective date, and complete
the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Practice Location Name (“Doing Business As” Name)
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)
Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Medicare Identification Number for this location – PTAN (if issued)

CMS-855B (XX/XX)

ZIP Code + 4
National Provider Identifier (NPI)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS)
NOTE: Only report organizations in this section. Individuals must be reported in section 6.
Complete this section with information about all organizations that have 5 percent or more (direct or
indirect) ownership interest of, any partnership interest in, and/or managing control of the supplier
identified in section 2, as well as information on any final adverse legal actions that have been imposed
against that organization. For examples of organizations that should be reported here, visit our Web site:
CMS.hhs.gov/MedicareProviderSupEnroll. If there is more than one organization that should be reported, copy
and complete this section for each.
NOTE: It is not necessary for the organization reported in 2A1 to report itself in this section.
The supplier must submit an organizational structure diagram/flowchart identifying all the entities listed in
section 5 and their relationships with the supplier and each other.

MANAGING CONTROL (ORGANIZATIONS)
Any organization that exercises operational or managerial control over the supplier, or conducts the day-today operations of the supplier, is a managing organization and must be reported. The organization need not
have an ownership interest in the supplier in order to qualify as a managing organization.
Report the entity under the role of “managing control” if, for instance, an entity:
a. has direct responsibility for the performance of your organization AND
b. is capable of changing the leadership, allocation of resources, or other processes of your organization to
improve performance.
Suppliers should also report any managing relationship with a management services organization under
contract with the supplier to furnish management services for the business.
Faculty practice plans, university-based health systems, hospital outpatient departments, medical foundations,
and groups that primarily treat enrollees of group model HMOs should review this definition of managing
control (organizations) carefully to determine if it applies

SPECIAL TYPES OF ORGANIZATIONS
Governmental/Tribal Organizations
If a federal, state, county, city or other level of government, or an Indian tribe, will be legally and financially
responsible for Medicare payments received (including any potential overpayments), the name of that
government or Indian tribe should be reported as an owner. The supplier must submit a letter on the
letterhead of the responsible government (e.g., government agency) or tribal organization that attests that
the government or tribal organization will be legally and financially responsible in the event that there is
any outstanding debt owed to CMS. This letter must be signed by an appointed or elected official of the
government or tribal organization who has the authority to legally and financially bind the government or
tribal organization to the laws, regulations, and program instructions of the Medicare program.

Non-Profit, Charitable and Religious Organizations
Many non-profit organizations are charitable or religious in nature, and are operated and/or managed by
a board of trustees or other governing body. The actual name of the board of trustees or other governing
body should be reported in this section. While the organization should be listed in section 5, individual board
members should be listed in section 6. Each non-profit organization should submit a copy of a 501(c)(3)
document verifying its non-profit status.

CMS-855B (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
NOTE: All organizations that complete this section must also complete section 5B.
All organizations that have any of the following must be reported in section 5:
• 5 percent or more direct or indirect ownership of the supplier,
• Managing control of the supplier, or
• Any general or limited partnership interest in the supplier, regardless of the percentage of ownership the
partner has
• A management services organization under contract with the supplier to furnish management services for
the business
Owning/Managing organizations are generally one of the following types:
• Corporations (including non-profit corporations)
• General Partnerships and Limited Partnerships (as indicated above)
• Limited Liability Companies
• Charitable and/or Religious organizations
• Governmental and/or Tribal organizations

A. ORGANIZATION WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL—
IDENTIFICATION INFORMATION
Not Applicable
If you are changing, adding or removing information about your current ownership interest and/or managing
control information for this organization, check the applicable box, furnish the effective date, and complete
the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Check all that apply:
5 Percent or More Ownership Interest Partner Managing Control
Indirect Ownership General Partner Limited Partner.

Direct Ownership

Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number (if applicable)

State
Fax Number (if applicable)

National Provider Identifier (NPI) (if issued)

ZIP Code + 4
E-mail Address (if applicable)

Tax Identification Number (Required)

What is the effective date this owner acquired ownership of the supplier identified in section 2A1 of this application? (mm/dd/yyyy)
What is the effective date this organization acquired managing control of the supplier identified in section 2A1 of this application?
(mm/dd/yyyy)

NOTE: Furnish both dates if applicable.

CMS-855B (XX/XX)

SECTION 5: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(ORGANIZATIONS) (Continued)
B. FINAL ADVERSE LEGAL ACTION
Complete this section for the organization reported in section 5A above. If you need additional information
regarding what to report, please refer to section 3 of this application.
NOTE: If reporting more than one organization, copy and complete sections 5A and 5B for each organization
reported.
1. Has this organization in section 5A above, under any current or former name or business identity, had a
final adverse legal action listed in section 3 of this application imposed against it?
YES – continue below

NO – skip to section 6

2. If yes, report each final adverse legal action, when it occurred, and the federal or state agency or the
court/administrative body that imposed the action.
NOTE: To satisfy the reporting requirement, section 5B2 must be filled out in its entirety, and all applicable
attachments must be included.
FINAL ADVERSE LEGAL ACTION

CMS-855B (XX/XX)

DATE

ACTION TAKEN BY

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS)
NOTE: Only report individuals in this section. Organizations must be reported in section 5.
NOTE: A supplier MUST have at least ONE organizational or individual owner, ONE managing employee and
ONE Authorized Official. In addition, all Authorized Officials and/or Delegated Officials must complete this
section, as well as the individuals listed below.
The following individuals must be reported in section 6A:
• All persons who have a 5 percent or greater direct or indirect ownership interest in the supplier (For
more information on “direct” and “indirect” owners, go to CMS.gov/Medicare/Provider-Enrollment-andCertification.);
• If (and only if) the supplier is a corporation (whether for-profit or non-profit), all officers and directors of
the supplier;
• All managing employees of the supplier;
• All individuals with a general or limited interest in the supplier, regardless of the percentage of ownership
the partner has; and
• Authorized and delegated officials. All Authorized Officials must identify one other relationship of 5%
or greater direct/indirect owner, Partner or Director/Officer. All Delegated Officials must identify one
other relationship but can select managing employee as other relationship. NOTE: If you need additional
information regarding who to report, please refer to section 15 of this application.
Example: A supplier is 100 percent owned by Company C, which itself is 100 percent owned by Individual D.
Assume that Company C is reported in section 5A as an owner of the supplier. Assume further that Individual
D, as an indirect owner of the supplier, is reported in section 6A. Based on this example, the supplier would
check the “5 percent or Greater Direct/Indirect Owner” box in section 6A.
NOTE: All partners within a partnership must be reported on this application. This applies to both “General”
and “Limited” partnerships. For instance, if a limited partnership has several limited partners and each of them
only has a 1 percent interest in the supplier, each limited partner must be reported on this application, even
though each owns less than 5 percent. The 5 percent threshold primarily applies to corporations and other
organizations that are not partnerships.
Non-Profit, Charitable or Religious Organizations: If you are a non-profit charitable or religious organization
that has no organizational or individual owners (only board members, directors or managers), you should
complete this section and submit a 501(c)(3) document verifying non-profit status with your application.
For purposes of this application, the terms “officer,” “director,” and “managing employee” are defined as
follows:
• Officer is any person whose position is listed as being that of an officer in the supplier’s “articles of
incorporation” or “corporate bylaws,” or anyone who is appointed by the board of directors as an officer in
accordance with the supplier’s corporate bylaws.
• Director is a member of the supplier’s “board of directors.” It does not necessarily include a person who
may have the word “director” in his/her job title (e.g., departmental director, director of operations).
Moreover, where a supplier has a governing body that does not use the term “board of directors,” the
members of that governing body will still be considered “directors.” Thus, if the supplier has a governing
body titled “board of trustees” (as opposed to “board of directors”), the individual trustees are considered
“directors” for Medicare enrollment purposes.
• 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.
NOTE: If a governmental or tribal organization will be legally and financially responsible for Medicare
payments received (per the instructions for Governmental/Tribal Organizations in section 5), the supplier is
only required to report its managing employees in section 6. Owners, partners, officers, and directors do not
need to be reported, except those who are listed as authorized or delegated officials on this application.
Any information on final adverse legal actions that have been imposed against the individuals reported in
section 6A must be furnished. If there is more than one individual, copy and complete this section for each
individual.
CMS-855B (XX/XX)

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS) (Continued)
A. INDIVIDUALS WITH OWNERSHIP INTEREST AND/OR MANAGING CONTROL—
IDENTIFICATION INFORMATION
If you are changing, adding, or removing information about your current ownership interest and/or managing
control information for this individual, check the applicable box, furnish the effective date, and complete the
appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):

The name, date of birth, and social security number of each person listed in this section must
coincide with the individual’s information as listed with the Social Security Administration. IRS issues
Individual Tax Identification Numbers (ITINs) to foreign nationals and others who have federal tax
reporting or filing requirements and are not eligible to obtain a Social Security Number (SSN) from
the Social Security Administration (SSA). Please report your ITIN in this section, if applicable.
First Name

Middle Initial

Last Name

Title

Jr., Sr.,M.D., etc.
Date of Birth (mm/dd/yyyy)

Social Security Number (SSN) or Individual Tax Identification Number (ITIN)
Telephone Number (if applicable)

Fax Number (if applicable)

E-mail Address (if applicable)

What is the above individual’s relationship with the supplier in section 2A1?
5 Percent or Greater Direct/Indirect Owner
Director/Officer
Authorized Official
General Partner
Limited Partner
Contracted Managing Employee
W-2 Managing Employee
Delegated Official
What is the effective date this owner acquired ownership of the supplier identified in section 2A1 of this
application? (mm/dd/yyyy)
What is the effective date this individual acquired managing control of the supplier identified in section 2A1
of this application? (mm/dd/yyyy)
NOTE: Furnish both dates if applicable.

CMS-855B (XX/XX)

SECTION 6: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION
(INDIVIDUALS) (Continued)
B. FINAL ADVERSE LEGAL ACTION
Complete this section for the individual reported in section 6A above. If you need additional information
regarding what to report, please refer to section 3 of this application.
NOTE: If reporting more than one individual, copy and complete sections 6A and 6B for each individual
reported.
1. Has the individual in section 6A above, under any current or former name or business identity, had a final
adverse legal action listed in section 3 of this application imposed against him/her?
YES – continue below

NO – skip to section 8

2. If yes, report each final adverse legal action, when it occurred, and the federal or state agency or the
court/administrative body that imposed the action.
NOTE: To satisfy the reporting requirement, section 6B2 must be filled out in its entirety, and all applicable
attachments must be included.
FINAL ADVERSE LEGAL ACTION

DATE

ACTION TAKEN BY

SECTION 7: THIS SECTION INTENTIONALLY LEFT BLANK

CMS-855B (XX/XX)

SECTION 8: BILLING AGENCY/AGENT INFORMATION
A billing agency/agent is a company or individual that you contract with to prepare and submit your claims.
If you use a billing agency/agent you must complete this section. Even if you use a billing agency/agent, you
remain responsible for the accuracy of the claims submitted on your behalf.
NOTE: The billing agency/agent address cannot be the correspondence mailing address completed in section
2A3 of this application.
Check here if this section does not apply and skip to section 12.
If you are changing information about your current billing agency/agent or adding or removing billing agency/
agent information, check the applicable box, furnish the effective date, and complete the appropriate fields in
this section.
Change Add Remove Effective Date (mm/dd/yyyy):

BILLING AGENCY/AGENT NAME AND ADDRESS
Legal Business as reported to the Internal Revenue Service or Individual Name as Reported to the Social Security Administration
If Billing Agent: Date of Birth (mm/dd/yyyy)
Billing Agency Tax Identification Number or Billing Agent Social Security Number (required)
Billing Agency/Agent “Doing Business As” Name (if applicable)
Billing Agency/Agent Address Line 1 (Street Name and Number)
Billing Agency/Agent Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address

SECTION 9: THIS SECTION INTENTIONALLY LEFT BLANK
SECTION 10: THIS SECTION INTENTIONALLY LEFT BLANK
SECTION 11: THIS SECTION INTENTIONALLY LEFT BLANK

CMS-855B (XX/XX)

SECTION 12: SUPPORTING DOCUMENTATION INFORMATION
This section lists the documents that, if applicable, must be submitted with this completed enrollment
application. If you are enrolling for the first time, or reactivating or revalidating your enrollment you must
submit applicable documents. When reporting a change of information, only submit documents that apply to
the change reported. Your designated Medicare Administrative Contractor (MAC) may request, at any time
during the enrollment process, documentation to support or validate information reported on this application.
In addition, your designated MAC may also request documents from you other than those identified in this
section as are necessary to ensure correct billing of Medicare.
Licenses, certifications and registrations required by Medicare or State law.
Federal, State/Territory, and/or local (city/county) business licenses, certifications and/or registrations required
to operate a health care facility.
Copy(s) of all final adverse legal action documentation (e.g., notifications, resolutions, and reinstatement
letters).
Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.
NOTE: The CMS-460 must be submitted for all initial enrollments or reactivations only if you want to be a
participating supplier in Medicare.
Completed Form CMS-588, Electronic Funds Transfer Authorization Agreement. Include a voided check or
bank letter.
NOTE: If you currently receive payments electronically and are not making a change to your banking
information, the CMS-588 is not required.
Copy(s) of all bills of sale or sales agreements for all ownership changes. This includes, CHOWS, Acquisition/
Mergers, and Consolidations, and all other ownership changes that are required to be reported, regardless of
the percentage involved (e.g., new 15 percent owner).
If Medicare payments due to you are being sent to a bank (or similar financial institution) where you have a
lending relationship (that is, any type of loan), you 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 Tax Identification Number and Legal Business Name
provided in section 2A (e.g., IRS form CP-575).
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.
Written confirmation from the IRS if your business is registered as a Limited Liability Company (LLC), including
single member LLCs, confirming your LLC is automatically classified as a Disregarded Entity (e.g., IRS Form
8832).
NOTE: A Disregarded Entity is an eligible entity that is not treated as a separate entity from its single owner
for income tax purposes.
Copy of IRS Determination Letter if you are registered with the IRS as non-profit (e.g., IRS Form 501(c)(3)).
NOTE: Government-owned entities do not need to provide an IRS Form 501(c)(3).
Organizational structure diagram/flowchart identifying all of the entities listed in section 5 and their
relationships with the supplier and each other.
Copy of an attestation for government entities and tribal organizations.
Copy of all ambulances’ licenses (NOTE: required for all application submissions, including a change of
information).
Copy of all mobile vehicle registrations (all mobile services including ambulance vehicles).
Copy of FAA 135 Certificate (air ambulance suppliers).
Copy(s) of comprehensive liability insurance policy (IDTFs only).
Copy(s) of all documentation verifying IDTF Supervisory Physician(s) proficiency and/or state licenses or
certifications for IDTF non-physician personnel.
Copy(s) of all documentation verifying the state licenses or certifications of the laboratory Director or nonphysician practitioner personnel of an independent clinical laboratory.
Copy of the Opioid Treatment Program approval letter.
Copy of the Opioid Treatment Program’s operating certificate.
Copy of all mobile vehicle registrations (all mobile services).
Copy(s) of certification documentation (CMS-1561 Health Insurance Benefit Agreement for newly enrolling
OTPs, CMS-1880 Request for Certification as Supplier of Portable X-Ray Services, CMS-370 ASC supplier
agreement).
CMS-855B (XX/XX)

SECTION 13: CONTACT PERSON INFORMATION (Optional)
If questions arise during the processing of this application, your designated MAC will contact the individual
reported below.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name

Middle Initial

Last Name

Jr., Sr.,M.D., etc.

Contact Person Address Line 1 (Street Name and Number)
Contact Person Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address

Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.)

NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this or any
other enrollment application. Your designated MAC will not discuss any other Medicare issues about you with
the above Contact Person.

CMS-855B (XX/XX)

SECTION 14: PENALTIES FOR FALSIFYING INFORMATION ON THIS APPLICATION
This section explains the penalties for deliberately furnishing false information in this application to gain or
maintain enrollment in the Medicare program.
1. 18 U.S.C. section 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. section 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.
3. The Civil False Claims Act, 31 U.S.C. Section 3729, imposes civil liability, in part, on any person who, with
actual knowledge, deliberate ignorance or reckless disregard of truth or falsity (a) presents or causes to
be presented to the United States Government or its contractor or agent a false or fraudulent claim for
payment or approval; (b) uses or causes to be used a false record or statement material either to a false or
fraudulent claim or to an obligation to pay the Government; (c) conceals or improperly avoids or decreases
an obligation to pay or transmit money or property to the Government; or (d) conspires to violate any
provision of the False Claims Act. The False Claims Act imposes a civil penalty of between $5,000 and
$10,000 per violation, as adjusted for inflation by the Federal Civil Penalties Inflation Adjustment Act, 28
U.S.C. 2461, plus three times the amount of damages sustained by the Government.
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.
6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute, or
attempt, to execute 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 United States Government may assert common law claims such as “common law fraud,” “money paid
by mistake,” and “unjust enrichment.” Remedies include compensatory and punitive damages, restitution,
and recovery of the amount of the unjust profit.

CMS-855B (XX/XX)

SECTION 15: CERTIFICATION STATEMENT
An Authorized Official is defined as an appointed official (for example, chief executive officer, chief financial
officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the
legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s status
in the Medicare program, and to commit the organization to fully abide by the statutes, regulations, and
program instructions of the Medicare program.
A Delegated Official is defined as an individual who is delegated by an authorized official the authority to
report changes and updates to the supplier’s enrollment record. A delegated official must be an individual
with an “ownership or control interest” in (as that term is defined in section 1124(a)(3) of the Social Security
Act), or be a W-2 managing employee of the supplier.
Delegated officials may not delegate their authority to any other individual. Only an authorized official
may delegate the authority to make changes and/or updates to the supplier’s Medicare status. Even when
delegated officials are reported in this application, an authorized official retains the authority to make
any such changes and/or updates by providing his or her printed name, signature, and date of signature as
required in section 15B.
NOTE: Authorized officials and delegated officials must be reported in section 6, either on this application or
on a previous application to this same MAC. If this is the first time an authorized and/or delegated official has
been reported on the CMS-855B, you must complete section 6 for that individual and that individual must sign
section 15.
By his/her signature(s), an authorized official binds the supplier to all of the requirements listed in the
Certification Statement and acknowledges that the supplier may be denied entry to or revoked from the
Medicare program if any requirements are not met.
Only an authorized official has the authority to sign (1) the initial enrollment application on behalf of the
supplier and (2) add or remove additional authorized officials and delegated officials. Once the delegation
of authority has been established all other enrollment application submissions can be signed by either an
authorized official or delegated official.
By signing this application, an authorized official agrees to immediately notify the MAC if any information
furnished on this application is not true, correct, or complete. In addition, an authorized official, by his/her
signature, agrees to notify the MAC of any future changes to the information contained in this form, after
the supplier is enrolled in Medicare, in accordance with the timeframes established in 42 C.F.R. 424.516. (IDTF
changes of information must be reported in accordance with 42 C.F.R. 410.33.)
The supplier can have as many authorized officials as it wants. If the supplier has more than two authorized
officials, it should copy and complete this section as needed.

Each authorized and delegated official must have and
disclose his/her Social Security Number.

CMS-855B (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
A. ADDITIONAL REQUIREMENTS FOR MEDICARE ENROLLMENT FOR AUTHORIZED OFFICIALS
These are additional requirements that the supplier must meet and maintain in order to bill the Medicare
program. Read these requirements carefully. By signing, the supplier is attesting to having read the
requirements and understanding them.
By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in section
15D agree to adhere to the following requirements stated in this Certification Statement:
1. I authorize the Medicare contractor to verify the information contained herein. I agree to notify
the Medicare contractor of any future changes to the information contained in this application in
accordance with the timeframes established in 42 C.F.R. section 424.516. I understand that any change in
the business structure of this supplier may require the submission of a new application.
2. I have read and understand the Penalties for Falsifying Information, as printed in this application. I
understand that any 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.
3. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to
the organization listed in section 2A1 of this application. The Medicare laws, regulations, and program
instructions are available through the Medicare Administrative 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, 42 U.S.C. section 1320a-7b(b) (section 1128B(b) of the Social Security Act) and the Physician SelfReferral Law (Stark Law), 42 U.S.C. section 1395nn (Section 1877 of the Social Security Act)).
4. Neither this supplier, nor any five percent or greater owner, partner, officer, director, managing
employee, authorized official, or delegated official thereof 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 supplying services to Medicare or other Federal program
beneficiaries.
5. I agree that any existing or future overpayment made to the supplier by the Medicare program may be
recouped by Medicare through the withholding of future payments.
6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by
Medicare, and I will not submit claims with deliberate ignorance or reckless disregard of their truth or
falsity.
7. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting
the Medicare program participation requirements, to release to any authorized representative,
employee, or agent of the Centers for Medicare & Medicaid Services (CMS), a copy of my most recent
accreditation survey, together with any information related to the survey that CMS may require
(including corrective action plans).

CMS-855B (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
B. AUTHORIZED OFFICIAL SIGNATURE(S)
1. 1st Authorized Official Signature
I have read the contents of this application. My signature legally and financially binds this supplier to the laws,
regulations, and program instructions of the Medicare program. By my signature, I certify that the information
contained herein is true, correct, and complete and I authorize the MAC to verify this information. If I become
aware that any information in this application is not true, correct, or complete, I agree to notify the MAC of
this fact in accordance with the time frames established in 42 C.F.R. section 424.516.
If you are adding or removing an authorized official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add Remove Effective Date (mm/dd/yyyy):
Authorized Official’s Information and Signature
First Name
Telephone Number

Middle Initial

Last Name

Jr., Sr., M.D., etc.

Title/Position

Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

2. 2nd Authorized Official Signature (if applicable)
I have read the contents of this application. My signature legally and financially binds this supplier to the laws,
regulations, and program instructions of the Medicare program. By my signature, I certify that the information
contained herein is true, correct, and complete and I authorize the MAC to verify this information. If I become
aware that any information in this application is not true, correct, or complete, I agree to notify the MAC of
this fact in accordance with the time frames established in 42 C.F.R. section 424.516.
If you are adding or removing an authorized official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add Remove Effective Date (mm/dd/yyyy):
Authorized Official’s Information and Signature
First Name
Telephone Number

Middle Initial

Last Name

Jr., Sr., M.D., etc.

Title/Position

Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

CMS-855B (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
C. ADDITIONAL REQUIREMENTS FOR MEDICARE ENROLLMENT FOR DELEGATED OFFICIALS
NOTE: Delegated Officials are optional.
1. You are not required to have a delegated official. However, if no delegated official is assigned, the
authorized official(s) will be the only person(s) who can make changes and/or updates to the supplier’s
status in the Medicare program.
2. The signature of a delegated official shall have the same force and effect as that of an authorized official,
and shall legally and financially bind the supplier to the laws, regulations, and program instructions of
the Medicare program. By his or her signature, the delegated official certifies that he or she has read the
Certification Statement in section 15 and agrees to adhere to all of the stated requirements. A delegated
official also certifies that he/she meets the definition of a delegated official. When making changes and/or
updates to the supplier’s enrollment information maintained by the Medicare program, a delegated official
certifies that the information provided is true, correct, and complete.
3. Delegated officials being removed do not have to sign or date this application.
4. Independent contractors are not considered “employed” by the supplier, and therefore cannot be
delegated officials.
5. The signature(s) of an authorized official in section 15B constitutes a legal delegation of authority to all
delegated official(s) assigned in section 15D.
6. If there are more than two individuals, copy and complete this section for each individual.

CMS-855B (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
D. DELEGATED OFFICIAL SIGNATURE(S)
1. 1st Delegated Official Signature
If you are adding or removing a delegated official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add Remove Effective Date (mm/dd/yyyy):
Delegated Official’s Information and Signature
Delegated Official First Name

Middle Initial

Last Name

Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Check here if Delegated Official is a W-2 Employee

Jr., Sr., M.D., etc.
Date Signed (mm/dd/yyyy)

Telephone Number

Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.
2. 2nd Delegated Official Signature
If you are adding or removing a delegated official, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Add Remove Effective Date (mm/dd/yyyy):
Delegated Official’s Information and Signature
Delegated Official First Name

Middle Initial

Last Name

Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Check here if Delegated Official is a W-2 Employee

Jr., Sr., M.D., etc.
Date Signed (mm/dd/yyyy)

Telephone Number

Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

CMS-855B (XX/XX)

SECTION 15: CERTIFICATION STATEMENT (Continued)
E. INDIVIDUAL PRACTITIONER CERTIFICATION STATEMENT AND SIGNATURE FOR
REASSIGNMENT OF BENEFITS
Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to
be paid to another individual or organization/group except in certain limited circumstances such as when the
individual practitioner who provided the services specifically authorizes another individual or organization/
group to receive said payments in accordance with 42 C.F.R. section 424.80. By signing this Certification
Statement, you are authorizing the organization/group identified in Section 2A1 to receive Medicare payments
on your behalf.
The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of
benefits, between the individual practitioner shown in Section 4H and the organization/group shown in
Section 2A1.
The employment of, or contract between, the individual practitioner and organization/group must be in
compliance with CMS regulations and applicable Medicare program safeguard standards described in 42 C.F.R.
section 424.80.
These signatures also serve as an attestation and acknowledgment to the compliance with all laws and
regulations pertaining to the reassignment of Medicare benefits. NOTE: A signature is only required in this
section if the application is submitted to establish, change or terminate a reassignment of benefits.

1. Individual Practitioner Signature
Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete.
I understand that any misrepresentation or concealment of any information requested in this application may
subject me and/or the organization/group to liability under civil and criminal laws.
Individual Practitioner First Name (Print)

Middle Initial

Last Name

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

Jr., Sr., M.D., etc.
Date Signed (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information
collection is 0938-1377. Various sections of the Social Security Act, the United States Code (U.S.C.), Internal Revenue Service (IRS) Code and
the CFR require suppliers to furnish information concerning the amounts due and the identification of individuals or entities that furnish
medical services to beneficiaries before payment can be made. The CMS-855B application collects this information, including the data
required to uniquely identify and enumerate the supplier. Additional information needed to process claims accurately and timely is also
collected on the application. The data collection helps CMS ensure that the supplier meets all statutory and regulatory requirements, and
suppliers must complete the CMS-855B application to obtain and retain the ability to receive Medicare payments consistent with Section
1866(j) of the Social Security Act.
The time required to complete this information collection is estimated at 0.5 to 3 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 or e-mail [email protected].
CMS will comply with all Privacy Act, Freedom of Information laws, and regulations that apply to this collection. Privileged or confidential
commercial or financial information is protected from public disclosure by federal law 5 U.S.C. 552(b)(4) and Executive Order 12600.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
CMS-855B (XX/XX)

ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS
All ambulance service suppliers enrolling in the Medicare program must complete this attachment.

A. AMBULANCE SUPPLIER TRANSPORT TYPE
This section is to be completed to indicate which ambulance service(s) you intend to provide.
If you are reporting a change to your ambulance supplier transport type, check the box below. This will
replace any ambulance supplier transport type currently on file.
Change Effective Date (mm/dd/yyyy):
Are you enrolling as a:
Non-Emergency Ambulance
Emergency Ambulance
Both a Non-Emergency Ambulance and an Emergency Ambulance.

B. GEOGRAPHIC AREA
This section is to be completed with information about the geographic area in which this company provides
ambulance services.
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Provide the city/town, and/or county, state/territory, and ZIP code for all locations where this ambulance
company renders services.
NOTE: If the ambulance company has vehicles garaged within a different Medicare contractor’s jurisdiction,
a separate CMS-855B enrollment application must be submitted to that Medicare Administrative Contractor
(MAC).

1. Initial Reporting and/or Additions
If services are provided in selected cities/towns, and/or counties, provide the locations below. List ZIP codes
only if they are not within the entire city/town.
CITY/TOWN

COUNTY

STATE/ TERRITORY

ZIP CODE

2. Deletions
If services are no longer provided in selected cities/towns, and/or counties, provide the locations below. List ZIP
codes only if they are not within the entire city/town.
CITY/TOWN

CMS-855B (XX/XX)

COUNTY

STATE/ TERRITORY

ZIP CODE

ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS (Continued)
C. STATE LICENSE INFORMATION
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Crew members must complete continuing education requirements in accordance with state and local licensing
laws. Evidence of re-certification must be retained with the employer in case it is required by the MAC.
Is this ambulance company licensed in the state where services are rendered and billed for?.......

Yes

If NO, explain why:

If YES, provide the license information for the state where this ambulance service supplier will be rendering
services and billing Medicare. Attach a copy of the current state license.
License Number
Effective Date (mm/dd/yyyy)

CMS-855B (XX/XX)

Issuing State (if applicable)

Issuing City/Town (if applicable)

Expiration Date (mm/dd/yyyy)

ATTACHMENT 1: AMBULANCE SERVICE SUPPLIERS (Continued)
D. VEHICLE INFORMATION
Complete this section with information about the vehicles used by this ambulance company and the services
they provide. If there is more than one vehicle, copy and complete this section as needed. Attach a copy of
each vehicle registration.
To qualify as an air ambulance supplier, it is required that the air ambulance supplier has proof that the
enrolling ambulance company, or the company leasing the air ambulance vehicle to the enrolling ambulance
company, possesses a valid charter flight license (FAA 135 Certificate) for the aircraft being used as an
air ambulance. If the enrolling ambulance company owns the aircraft, the owner’s name on the FAA 135
Certificate must be the same as the enrolling ambulance company’s name (or the ambulance company owner
as reported in sections 5 or 6) in this application. If the enrolling ambulance company leases the aircraft from
another company, a copy of the lease agreement must accompany this enrollment application.
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
Type (automobile, aircraft, boat, etc.)

Vehicle Identification Number

Make (e.g., Ford)

Model (e.g., 350T)

Year (yyyy)

Does this vehicle provide:
Advanced life support (Level 1).........

YES

Advanced life support (Level 2).........

YES

Basic life support.................................

YES

Emergency runs...................................

YES

Non-emergency runs ..........................

YES

Specialty care transport......................

YES

Land ambulance..................................

YES

Air ambulance–fixed wing.................

YES

Air ambulance–rotary wing................

YES

Marine ambulance..............................

YES

CMS-855B (XX/XX)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs)
INDEPENDENT DIAGNOSTIC TESTING FACILITY (IDTF) PERFORMANCE STANDARDS
Below is a list of the performance standards that an IDTF must meet in order to obtain or maintain their
Medicare billing privileges. These standards, in their entirety, can be found in 42 C.F.R section 410.33(g).
1. Operate its business in compliance with all applicable Federal and State licensure and regulatory
requirements for the health and safety of patients.
2. Provides complete and accurate information on its enrollment application. Changes in ownership,
changes of location, changes in general supervision, and adverse legal actions must be reported to the
Medicare Administrative Contractor (MAC) on the Medicare enrollment application within 30 calendar
days of the change. All other changes to the enrollment application must be reported within 90 calendar
days.
3. Maintain a physical facility on an appropriate site. For the purposes of this standard, a post office box,
commercial mail box, hotel or motel is not considered an appropriate site.
a. The physical facility, including mobile units, must contain space for equipment appropriate to the
services designated on the enrollment application, facilities for hand washing, adequate patient
privacy accommodations, and the storage of both business records and current medical records within
the office setting of the IDTF, or IDTF home office, not within the actual mobile unit.
b. IDTF suppliers that provide services remotely and do not see beneficiaries at their practice location
are exempt from providing hand washing and adequate patient privacy accommodations.
4. Have all applicable diagnostic testing equipment available at the physical site excluding portable
diagnostic testing equipment. A catalog of portable diagnostic equipment, including diagnostic testing
equipment serial numbers, must be maintained at the physical site. In addition, portable diagnostic
testing equipment must be available for inspection within two business days of a CMS inspection
request. The IDTF must maintain a current inventory of the diagnostic testing equipment, including
serial and registration numbers, provide this information to the MAC upon request, and notify the MAC
of any changes in equipment within 90 days.
5. Maintain a primary business phone under the name of the designated business. The primary business
phone must be located at the designated site of the business, or within the home office of the mobile
IDTF units. The telephone number or toll free numbers must be available in a local directory and
through directory assistance.
6. Have a comprehensive liability insurance policy of at least $300,000 per location that covers both the
place of business and all customers and employees of the IDTF. The policy must be carried by a nonrelative owned company. Failure to maintain required insurance at all times will result in revocation of
the IDTF’s billing privileges retroactive to the date the insurance lapsed. IDTF suppliers are responsible
for providing the contact information for the issuing insurance agent and the underwriter. In addition,
the IDTF must:
a. Ensure that the insurance policy must remain in force at all times and provide coverage of at least
$300,000 per incident; and
b. Notify the CMS designated contractor in writing of any policy changes or cancellations.
7. Agree not to directly solicit patients, which include, but is not limited to, a prohibition on telephone,
computer, or in-person contacts. The IDTF must accept only those patients referred for diagnostic testing
by an attending physician, who is furnishing a consultation or treating a beneficiary for a specific
medical problem and who uses the results in the management of the beneficiary’s specific medical
problem. Non-physician practitioners may order tests as set forth in section 410.32(a)(3).
8. Answer, document, and maintain documentation of a beneficiary’s written clinical complaint at the
physical site of the IDTF (for mobile IDTFs, this documentation would be stored at their home office.)
This includes, but is not limited to, the following:
a. The name, address, telephone number, and Medicare beneficiary identifier of the beneficiary.
b. The date the complaint was received; the name of the person receiving the complaint; and a summary
of actions taken to resolve the complaint.
c. If an investigation was not conducted, the name of the person making the decision and the reason
for the decision.
CMS-855B (XX/XX)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
9. Openly post these standards for review by patients and the public.
10. Disclose to the government any person having ownership, financial, or control interest or any other legal
interest in the supplier at the time of enrollment or within 30 days of a change.
11. Have its testing equipment calibrated and maintained per equipment instructions and in compliance
with applicable manufacturers suggested maintenance and calibration standards.
12. Have technical staff on duty with the appropriate credentials to perform tests. The IDTF must be able
to produce the applicable federal or state licenses or certifications of the individuals performing these
services.
13. Have proper medical record storage and be able to retrieve medical records upon request from CMS or
the MAC within 2 business days.
14. Permit CMS, including its agents, or its MACs, to conduct unannounced, on-site inspections to confirm
the IDTF’s compliance with these standards. The IDTF must be accessible during regular business hours to
CMS and beneficiaries and must maintain a visible sign posting the normal business hours of the IDTF.
15. With the exception of hospital-based and mobile IDTFs, a fixed base IDTF does not include the following:
a. Sharing a practice location with another Medicare-enrolled individual or organization.
b. Leasing or subleasing its operations or its practice location to another Medicare enrolled individual or
organization.
c. Sharing diagnostic testing equipment using in the initial diagnostic test with another Medicare
enrolled individual or organization.
16. Enrolls in Medicare for any diagnostic testing services that it furnishes to a Medicare beneficiary,
regardless of whether the service is furnished in a mobile or fixed base location.
17. Bills for all mobile diagnostic services that are furnished to a Medicare beneficiary, unless the mobile
diagnostic service is part of a service provided under arrangement as described in section 1861(w)(1) of
the Act.

INSTRUCTIONS
If you perform diagnostic tests, other than clinical laboratory or pathology tests, and are required to enroll as
an IDTF, you must complete this attachment. CMS requires the information in this attachment to determine
whether the enrolling supplier meets all IDTF standards including, but not limited to, those listed above on
this application. Not all suppliers that perform diagnostic tests are required to enroll as an IDTF.
If the IDTF is deleting an Interpreting Physician, a Technician who performs tests, or a Supervising Physician
with this IDTF, complete section F of this attachment (below). Mail this attachment with original signatures
to your designated MAC (NOTE: Supervising Physicians must sign section F). The MAC that services your State
is responsible for processing your enrollment application information. To locate the mailing address for your
designated MAC, go to www.cms.gov/MedicareProviderSupEnroll.

DIAGNOSTIC RADIOLOGY
Many diagnostic tests are radiological procedures that require the professional services of a radiologist. A
radiologist’s practice is generally different from those of other physicians because radiologists usually do not
bill E&M codes or treat a patient’s medical condition on an ongoing basis. A radiologist or group practice of
radiologists is not necessarily required to enroll as an IDTF. If enrolling as a diagnostic radiology group practice
or clinic and billing for the technical component of diagnostic radiological tests without enrolling as an IDTF (if
the entity is a free standing diagnostic facility), it should contact the carrier to determine that it does not need
to enroll as an IDTF.
A mobile IDTF that provides X-ray services is not classified as a portable X-ray supplier. Regulations governing
IDTFs can be found at 42 C.F.R. 410.33.

CMS-855B (XX/XX)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
CPT-4 AND HCPCS CODES
Report all CPT-4 and HCPCS codes for which this IDTF will bill Medicare. Include the following:
• Provide the CPT-4 or HCPCS codes for which this IDTF intends to bill Medicare,
• The name and type of equipment used to perform the reported procedure, and
• The model number of the reported equipment.
The IDTF should report all Current Procedural Terminology, Version 4 (CPT-4) codes, Healthcare Common
Procedural Coding System codes (HCPCS), and types of equipment (including the model number), for which
it will perform tests, supervise, interpret, and/or bill. All codes reported must be for diagnostic tests that an
IDTF is allowed to perform. Diagnostic tests that are clearly surgical in nature, which must be performed in a
hospital or ambulatory surgical center, should not be reported.
Consistent with IDTF supplier standard 6 on page 37 of this application, all IDTFs enrolling in Medicare must
have a comprehensive liability insurance policy of at least $300,000 per location that covers both the place of
business and all customers and employees of the IDTF. The policy must be carried by a non- relative owned
company. Failure to maintain the required insurance at all times will result in revocation of the Medicare
supplier billing number, retroactive to the date the insurance lapsed. Malpractice insurance policies do not
demonstrate compliance with this requirement.
All IDTFs must submit a complete copy of the aforementioned liability insurance policy with this application.

A. STANDARDS QUALIFICATIONS
Provide the date this Independent Diagnostic Testing Facility met all current CMS standards (mm/dd/yyyy)

B. CPT-4 AND HCPCS CODES
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
All codes and modifiers (if applicable) reported here must be for diagnostic tests that an IDTF is allowed
to perform. Diagnostic tests that are clearly surgical in nature, which must be performed in a hospital or
ambulatory surgical center, should not be reported. Clinical laboratory and pathology codes should not be
reported. This page may be copied for additional codes or equipment.
CPT–4 or
HCPCS Code

Modifier
(if applicable)

Equipment

Model Number

Serial Number

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
CMS-855B (XX/XX)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
C. INTERPRETING PHYSICIAN INFORMATION
Check here if this section does not apply because the interpreting physician is enrolled in Medicare as an
individual and will bill separately from the IDTF.
When a mobile unit of the IDTF performs a technical component of a diagnostic test and the interpretive
physician is the same physician who ordered the test, the IDTF cannot bill for the interpretation. Therefore,
these interpreting physicians should not be reported since the interpretive physician must submit his/her own
claims for these tests.
All physicians whose interpretations will be billed by this IDTF with the technical component (TC) of the test
(i.e., global billing) must be listed in this section. If there are more than two physicians, copy and complete
this section as needed. All interpreting physicians must be currently enrolled in the Medicare program.
If you are billing for purchased interpretations, all requirements for purchased interpretations must be met.

1st Interpreting Physician 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.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name

Middle Initial

Last Name

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued)

NPI

Jr., Sr.,M.D., etc.

2nd Interpreting Physician 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.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name

Middle Initial

Last Name

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued)

NPI

CMS-855B (XX/XX)

Jr., Sr.,M.D., etc.

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
D. PERSONNEL (TECHNICIANS) WHO PERFORM TESTS
Complete this section with information about all non-physician personnel who perform tests for this IDTF.
NOTE: If there are more than two personnel (technicians), copy and complete this section as needed.

1st Personnel (Technician) Information
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name

Middle Initial

Social Security Number (SSN)

Last Name

Jr., Sr.,M.D., etc.

Date of Birth (mm/dd/yyyy) (Required)

Is this technician state licensed or state certified? (see instructions for clarification)....................
License/Certification Number (if applicable)

License/Certification Issue Date (mm/dd/yyyy) (if applicable)

State Where Issued

Is this technician certified by a national credentialing organization?.............................................
Name of credentialing organization (if applicable)

YES

Type of Credentials (if applicable)

2nd Personnel (Technician) Information
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name

Middle Initial

Social Security Number (SSN)

Last Name

Jr., Sr.,M.D., etc.

Date of Birth (mm/dd/yyyy) (Required)

Is this technician state licensed or state certified? (see instructions for clarification)....................
License/Certification Number (if applicable)

License/Certification Issue Date (mm/dd/yyyy) (if applicable)

CMS-855B (XX/XX)

State Where Issued

Is this technician certified by a national credentialing organization?.............................................
Name of credentialing organization (if applicable)

YES

Type of Credentials (if applicable)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
E. SUPERVISING PHYSICIANS
Complete this section with identifying information about the physician(s) who supervise the operation of the
IDTF and who provides the personal, direct, or general supervision per 42 C.F.R. 410.32(b)(3). The supervising
physician must also attest to his/her supervising responsibilities for the enrolling IDTF.
Information concerning the type of supervision (personal, direct, or general) required for performance of
specific IDTF tests can be obtained from your MAC. All IDTFs must report at least one supervisory physician,
and at least one supervising physician must perform the supervision requirements stated in 42 C.F.R. 410.32(b)
(3). All supervisory physician(s) must be currently enrolled in Medicare. Under 42 CFR section 410.33(b)(1), each
supervising physician must be limited to providing general supervision at no more than three IDTF sites. This
applies to both fixed sites and mobile units where three concurrent operations are capable of performing
tests.
The type of supervision being performed by each physician who signs the attestation in this section of this
application should be listed in this section.
NOTE: If there is more than one supervising physician, copy and complete this section for each.
Definitions of the types of supervision are as follows:
• Personal Supervision means a physician must be in attendance in the room during the performance of the
procedure.
• Direct Supervision means the physician must be present in the office suite and immediately available to
provide assistance and direction throughout the performance of the procedure. It does not mean that the
physician must be present in the room when the procedure is performed.
• General Supervision means the procedure is provided under the physician’s overall direction and control,
but the physician’s presence is not required during the performance of the procedure. General supervision
also includes the responsibility that the non-physician personnel who perform the tests are qualified and
properly trained and that the equipment is operated properly, maintained, calibrated and that necessary
supplies are available.
If you are changing, adding, or removing information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name

Middle Initial

Last Name

Social Security Number (Required)

Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued)

NPI

Telephone Number

CMS-855B (XX/XX)

Fax Number (if applicable)

Suffix (e.g., Jr., Sr.)

E-mail Address (if applicable)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
Type of Supervision Provided
Check the appropriate box below indicating the type of supervision provided by the physician reported above
for the tests performed by the IDTF in accordance with 42 C.F.R. 410.32 (b)(3) (See instructions for definitions).
Personal Supervision

Direct Supervision

General Supervision

NOTE: Each supervising physician must be limited to providing general supervision to no more than three IDTF
sites.
For each physician performing General Supervision, at least one of the three functions listed here must be
checked. However, to meet the General Supervision requirement, in accordance with 42 C.F.R. 410.33(b), the
enrolling IDTF must have at least one supervisory physician for each of the three functions. For example,
two physicians may be responsible for function 1, a third physician may be responsible for function 2, and a
fourth physician may be responsible for function 3. All four supervisory physicians must complete and sign
the supervisory physician section of this application. Each physician should only check the function(s) he/she
actually performs.
Assumes responsibility for the overall direction and control of the quality of testing performed.
Assumes responsibility for assuring that the non-physician personnel who actually perform the diagnostic
procedures are properly trained and meet required qualifications.
Assumes responsibility for the proper maintenance and calibration of the equipment and supplies necessary
to perform the diagnostic procedures.

Other Supervision Sites
Does this supervising physician provide supervision at any other IDTF?........................................

YES

If yes, list all other IDTFs for which this physician provides supervision. For more than five, copy this sheet.
NAME OF FACILITY

ADDRESS

TAX IDENTIFICATION
NUMBER

LEVEL OF
SUPERVISION

1.
2.
3.
4.
5.

CMS-855B (XX/XX)

ATTACHMENT 2: INDEPENDENT DIAGNOSTIC TESTING FACILITIES (IDTFs) (Continued)
Attestation Statement for Supervising Physicians
All Supervising Physician(s) rendering supervisory services for this IDTF must sign and date this section. All
signatures must be original.
1. I hereby acknowledge that I have agreed to provide (IDTF Name)___________________________with the
Supervisory Physician services checked above for all CPT-4 and HCPCS codes and modifiers (if applicable)
reported in this Attachment. (See number 2 below if all reported CPT-4 and HCPCS codes and modifiers
(if applicable) do not apply). I also hereby certify that I have the required proficiency in the performance
and interpretation of each type of diagnostic procedure, as reported by CPT-4 or HCPCS codes and modifiers (if applicable) in this Attachment (except for those CPT-4 or HCPCS codes and modifiers (if applicable) identified in number 2 below). I have read and understand the Penalties for Falsifying Information
on this Enrollment Application, as stated in Section 14 of this application. I am aware that falsifying
information may result in fines and/or imprisonment. If I undertake supervisory responsibility at any
additional IDTFs, I understand that it is my responsibility to notify this IDTF at that time.
2. I am not acting as a Supervising Physician for the following CPT-4 and/or HCPCS codes reported in this
Attachment.
CPT–4 OR HCPCS CODE

MODIFIER (if applicable)

CPT–4 OR HCPCS CODE

3. Signature of Supervising Physician (First, Middle, Last, Jr., Sr., M.D., D.O., etc.)

MODIFIER (if applicable)

Date (mm/dd/yyyy)

In order to process this application it MUST be signed and dated.

CMS-855B (XX/XX)

ATTACHMENT 3: OPIOID TREATMENT PROGRAM PERSONNEL
All Opioid Treatment Programs enrolling in the Medicare program must complete this attachment.

Information for Individuals Legally Authorized to Order and/or Dispense Controlled Substances at
OTP Facility

The OTP must include the following information for all employees, whether W-2 or not, and contracted staff,
who are legally authorized to order and/or dispense controlled substances, whether or not the individual is
currently ordering and/or dispensing at the OTP facility.

Ordering Personnel
•
•
•
•
•
•

First, Last Name, Middle Initial (if applicable)
Date of Birth
Social Security Number (SSN)
Practitioner Type
Active and Valid NPI
License Number

Dispensing Personnel
•
•
•
•
•
•

First, Last Name, Middle Initial (if applicable)
Date of Birth
Social Security Number (SSN)
Practitioner Type
Active and Valid NPI
License Number

Adverse History and Ineligibility

Under the OTP Standards in 42 C.F.R § 424.67, an OTP provider must not employ, as a W2 employee or not, or
contract with anyone who meets any of the ineligibility criteria outlined below, whether or not the individual
is currently ordering or dispensing at the OTP facility.
• Currently is revoked from Medicare under § 424.535 or any other applicable section in Title 42, and under
an active reenrollment bar.
• Currently is on the preclusion list pursuant to 42 C.F.R. § 422.222 or § 423.120(c)(6).
• Currently is excluded by the Department of Health and Human Services (DHHS) Office of Inspector General
(OIG).
• Has a prior action, including but not limited to a reprimand, fine, or restriction, by a state oversight board
for professional misconduct issues relating to patient harm.

CMS-855B (XX/XX)

ATTACHMENT 3: OPIOID TREATMENT PROGRAM PERSONNEL (Continued)
A. ORDERING PERSONNEL IDENTIFICATION
NOTE: Copy and complete this section if more than three OTP ORDERING personnel need to be reported.
If you are changing information about currently reported OTP ordering personnel or adding or removing OTP
personnel, check the applicable box, furnish the effective date, and complete the appropriate fields in this
section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name of OTP Ordering Personnel

Middle Initial

Last Name of OTP Ordering Personnel

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

NPI

License Number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner Type

If you are changing information about currently reported OTP ordering personnel or adding or removing OTP
personnel, check the applicable box, furnish the effective date, and complete the appropriate fields in this
section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name of OTP Ordering Personnel

Middle Initial

Last Name of OTP Ordering Personnel

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

NPI

License Number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner Type

Middle Initial

Last Name of OTP Ordering Personnel

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

NPI

License Number

Suffix (e.g., Jr., Sr., M.D., etc.)

Practitioner Type

CMS-855B (XX/XX)

ATTACHMENT 3: OPIOID TREATMENT PROGRAM PERSONNEL (Continued)
B. DISPENSING PERSONNEL IDENTIFICATION
NOTE: Copy and complete this section if more than three OTP DISPENSING personnel need to be reported.
If you are changing information about currently reported OTP Dispensing personnel or adding or removing
OTP personnel, check the applicable box, furnish the effective date, and complete the appropriate fields in this
section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name of OTP Dispensing Personnel

Middle Initial

Last Name of OTP Dispensing Personnel Suffix (e.g., Jr., Sr., M.D., etc.)

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

NPI

License Number

Practitioner Type

If you are changing information about currently reported OTP Dispensing personnel or adding or removing
OTP personnel, check the applicable box, furnish the effective date, and complete the appropriate fields in this
section.
Change Add Remove Effective Date (mm/dd/yyyy):
First Name of OTP Dispensing Personnel

Middle Initial

Last Name of OTP Dispensing Personnel Suffix (e.g., Jr., Sr., M.D., etc.)

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

NPI

License Number

Practitioner Type

Middle Initial

Last Name of OTP Dispensing Personnel Suffix (e.g., Jr., Sr., M.D., etc.)

Social Security Number (SSN)

Date of Birth (mm/dd/yyyy)

NPI

License Number

Practitioner Type

CMS-855B (XX/XX)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT
The Authority for maintenance of the system is given under provisions of sections 1102(a) (Title 42 U.S.C. 1302(a)), 1128
(42 U.S.C. 1320a–7), 1814(a)) (42 U.S.C. 1395f (a)(1), 1815(a) (42 U.S.C. 1395g(a)), 1833(e) (42 U.S.C. 1395I(3)),1871 (42 U.S.C.
1395hh), and 1886(d)(5)(F), (42 U.S.C. 1395ww(d)(5)(F) of the Social Security Act; 1842(r) (42 U.S.C.1395u(r)); section 1124(a)
(1) (42 U.S.C. 1320a–3(a)(1), and 1124A (42 U.S.C. 1320a–3a), section 4313, as amended, of the BBA of 1997; and section
31001(i) (31 U.S.C. 7701) of the DCIA (Pub. L. 04–134), as amended.
The information collected here will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
PECOS will collect information provided by an applicant related to identity, qualifications, practice locations, ownership,
billing agency information, reassignment of benefits, electronic funds transfer, the NPI and related organizations. PECOS
will also maintain information on business owners, chain home offices and provider/chain associations, managing/
directing employees, partners, authorized and delegated officials, supervising physicians of the supplier, ambulance
vehicle information, and/or interpreting physicians and related technicians. This system of records will contain the names,
social security numbers (SSN), date of birth (DOB), and employer identification numbers (EIN) and NPI’s for each disclosing
entity, owners with 5 percent or more ownership or control interest, as well as managing/directing employees. Managing/
directing employees include general manager, business managers, administrators, directors, and other individuals who
exercise operational or managerial control over the provider/ supplier. The system will also contain Medicare identification
numbers (i.e., CCN, PTAN and the NPI), demographic data, professional data, past and present history as well as
information regarding any adverse legal actions such as exclusions, sanctions, and felonious behavior.
The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used for
a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure of data
is known as a “routine use.” The CMS will only release PECOS information that can be associated with an individual
as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both identifiable and nonidentifiable data may be disclosed under a routine use. CMS will only collect the minimum personal data necessary to
achieve the purpose of PECOS. Below is an abbreviated summary of the six routine uses. To view the routine uses in their
entirety go to: CMS.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/Privacy/Downloads/0532PECOS.pdf.
1. To support CMS contractors, consultants, or grantees, who have been engaged by CMS to assist in the performance of a
service related to this collection and who need to have access to the records in order to perform the activity.
2. To assist another Federal or state agency, agency of a state government or its fiscal agent to:
a. Contribute to the accuracy of CMS’s proper payment of Medicare benefits,
b. Enable such agency to administer a Federal health benefits program that implements a health benefits program
funded in whole or in part with federal funds, and/or
c. Evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance operations.
3. To assist an individual or organization for research, evaluation or epidemiological projects related to the prevention of
disease or disability, or the restoration or maintenance of health, and for payment related projects.
4. To support the Department of Justice (DOJ), court or adjudicatory body when:
a. The agency or any component thereof, or
b. Any employee of the agency in his or her official capacity, or
c. Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the employee,
or
d. The United States Government, is a party to litigation and that the use of such records by the DOJ, court or
adjudicatory body is compatible with the purpose for which CMS collected the records.
5. To assist a CMS contractor that assists in the administration of a CMS administered health benefits program, or to
combat fraud, waste, or abuse in such program.
6. To assist another Federal agency to investigate potential fraud, waste, or abuse in, a health benefits program funded in
whole or in part by Federal funds.
The applicant 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. section 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. section 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. section 552(b)(4) and/or
(b)(6), respectively.

CMS-855B (XX/XX)

File Type	application/pdf
File Modified	2025-07-02
File Created	2024-06-18