Cms-855s Form - Cheat Sheet On Completing printable pdf download

Cheat Sheet on Completing the CMS-855S

It is important to read the instructions that are included with each section throughout the application form. If you fail to complete the

application properly, processing time will likely be delayed since we will then need to develop the application via phone and/or written

validation, depending on what needs to be completed. Do not use pencil on the CMS-855S form. Applications that are filled out in

pencil and/or signed with a rubber stamp, copy or in pencil will promptly be returned as “Unprocessable”. The CMS-855S form is a

legal document and must be treated as such. Read each section carefully and answer thoroughly. There are important check boxes in

each section that may be easily missed. Below you will find some tips in helping you to complete the CMS-855S. If you have any

questions, please call the toll free NSC Customer Service Center at 1-866-238-9652. Feel free to also browse through the NSC web site

for information ( à click on either Other Partners or Providers à select National Supplier Clearinghouse).

The CMS-885S form is to be used for enrollment of a new DMEPOS supplier number, re-enrollment, reactivation, enrollment of a new

location for a currently enrolled supplier, change of information, and voluntary termination of a billing number. Please mark the check

box selecting the reason for which you are filling out the form in section 1 on page 5.

NOTE: Although the 855S indicates that a supplier has 90 days to send in any change of information, the 21 Supplier Standards take

precedence over the application form. Please comply with Standard #2 by sending change of information within 30 days of the change.

FOR ALL ENROLLMENTS, RE-ENROLLMENTS, AND RE-ACTIVATIONS:

If you are a:

Complete sections:

Sole Proprietor/Individual

1, 2, 3, 4, 5A, 6, 8, 13, 15, 16, 17 – read section 14 carefully.

Business/Professional/Limited Liability

1, 2, 3, 4, 5B-5C, 6, 8, 13, 15, 16, 17 – read section 14 carefully.

Corporation

General Partner OR Joint Venture

1, 2, 3, 4, 5A OR 5B-5C (as applicable), 6, 8, 13, 15, 16, 17 – read section 14 carefully.

Please note that surety bonds are not required. Section 11 “Surety Bond Information” may be left blank on all applications.

FOR ALL CHANGES TO YOUR SUPPLIER FILE:

Select “Change of Information” in section 1.A.1, mark the sections (boxes 1 – 16) that you are changing, and write your supplier number

in the blank space beside the change option. Then in the section(s) where changes are being made, mark the “Change” check box at the

top of each section and complete the section. The appropriate authorized or delegated official must sign section 15 (Certification

Statement). Send the completed sections and any applicable attachments to the NSC at the address in the front of the application form.

FOR VOLUNTARY TERMINATION OF DMEPOS BILLING NUMBER:

Select “Voluntary Termination” in section 1.A.1, and write your supplier number in the blank space beside “Change of Information” right

above the voluntary termination check box. Enter the date of termination. Fill out section 2.A and 4.A for identification of supplier and

location. Only the authorized (not delegated) official can sign section 15 (Certification Statement) of a Voluntary Termination form.

DO NOT include the following: (The NSC does not do anything with this paperwork and it is not required.)

Form HCFA-588 mentioned under section 4.C.

The EDI contract that is mentioned in section 9. Please do not contact your DMERC to ask for this paperwork.

Final Checklist

Have you completed the appropriate sections?

Have you supplied all appropriate attachments? (Check section 17)

Have you included SSNs and EINs where required?

Did you verify that the following addresses are NOT P.O. boxes: Section 4A - Business Location, Section 4D – Location of patient

records, Section 8B – Billing Agency Address?

Did you sign Section 15 (no stamp, pencil or photocopy signatures)? Are the signatures those of persons who are authorized to sign?

Acceptable Authorized Official (only 1 per entity/tax

Owner, General Partner, Chairman of the Board, President, CEO, COO, CFO,

ID # – authorized official is not location specific.)

or must hold a position of similar status and authority.

Acceptable Delegated Official (up to 3 per entity/tax

Managing Employee (general manager, business manager, Administrator, or

ID # – delegated official is not location specific. If an

someone who exercises operational or managerial control over the company.)

entity wishes to add one and already has three, it must

Proof of employment may be required. This official may also be an

individual who holds 5% or more direct ownership interest in the company.

be decided which of the first three to delete.)

These individuals will be listed in section 6.

Revised 3/4/02

Cms-855s Form - Cheat Sheet On Completing

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