Form Cms-8550 - Medicare Enrollment Application Page 4

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SECTION 1: BASIC INFORMATION
A. REASON FOR SUBMITTING THIS APPLICATION
Check one box and complete the sections of this application as indicated.
Complete all sections
You are enrolling for the sole purpose of ordering/certifying and/or
prescribing Part D drugs
You are currently enrolled solely to order and certify and/or prescribe
Complete Section 2A, all other
applicable sections and Section 8
Part D drugs, and are updating your information
Complete Section 2A (Name, SSN
You are voluntarily withdrawing your Medicare enrollment to solely
order and certify and/or prescribe Part D drugs
and NPI) and Section 8
B. REASON YOU ARE ENROLLING SOLELY TO ORDER AND CERTIFY OR PRESCRIBE PART D DRUGS
Instructions: Choose only one reason from Group One OR one reason from Group Two
You are enrolling in Medicare solely to order and certify or prescribe Part D drugs because you are:
Group 1
Group 2
Employed by the DVA
Physician not employed by any entity in Group 1
Employed by the PHS
Eligible Professional not employed by any entity in
Group 1
Employed by the DOD/Tricare
Licensed Resident not employed by any entity in
Employed by the IHS or a Tribal Organization
Group 1
Employed by a Medicare-enrolled FQHC
Dentist not employed by any entity in Group 1
Employed by a Medicare-enrolled RHC
Pediatrician not employed by any entity in Group 1
Employed by a Medicare-enrolled CAH
Retired physicians who are licensed
Other (specify):
SECTION 2: IDENTIFYING INFORMATION
A. PERSONAL INFORMATION
Your name, date of birth, and social security number must match your social security record.
First Name
Middle Initial
Last Name
Jr., Sr., M.D., etc.
Other Name, First
Middle Initial
Last Name
Jr., Sr., M.D., etc.
Type of Other Name
Former or Maiden Name
Professional Name
Other (Describe):
Social Security Number (SSN)
Date of Birth (mm/dd/yyyy)
Gender
Male
Female
Medicare Identification Number (PTAN) (if issued)
National Provider Identifier (NPI) (Type 1 – Individual)
B. EDUCATIONAL INFORMATION
Medical or other Professional School (Training Institution, if non-MD)
Year of Graduation (yyyy)
C. LICENSE/CERTIFICATION/REGISTRATION INFORMATION
1. License Information
License Not Applicable
License Number
Effective Date (mm/dd/yyyy)
State Where Issued
2. Certification Information
Certification Not Applicable
Certification Number
Effective Date (mm/dd/yyyy)
State Where Issued
3. Drug Enforcement Agency (DEA) Registration Information
Registration Not Applicable
DEA Registration Number
Effective Date (mm/dd/yyyy)
State Where Issued
CMS-855O (01/17)
3

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