Form Cms-8550 - Medicare Enrollment Application Page 6

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SECTION 4: MEDICAL SPECIALTY INFORMATION
A. PHYSICIAN SPECIALTY
Check your primary specialty below. Only check one (1) specialty. Physicians must meet all state requirements
for the type of specialty checked.
Addiction Medicine
Nephrology
Allergy/Immunology
Neurology
Anesthesiology
Neuropsychiatry
Cardiac Electrophysiology
Neurosurgery
Cardiac Surgery
Nuclear Medicine
Cardiovascular Disease (Cardiology)
Obstetrics/Gynecology
Colorectal Surgery (Proctology)
Ophthalmology
Critical Care (Intensivists)
Optometry
Dentist
Oral Surgery
Dermatology
Orthopedic Surgery
Diagnostic Radiology
Osteopathic Manipulative Medicine
Emergency Medicine
Otolaryngology
Endocrinology
Pain Management
Family Practice
Pathology
Gastroenterology
Pediatric Medicine
General Practice
Peripheral Vascular Disease
General Surgery
Physical Medicine and Rehabilitation
Geriatric Medicine
Plastic and Reconstructive Surgery
Geriatric Psychiatry
Podiatry
Gynecological Oncology
Preventive Medicine
Hand Surgery
Psychiatry
Hematology
Pulmonary Disease
Hematology/Oncology
Radiation Oncology
Hospice/Palliative Care
Rheumatology
Infectious Disease
Sleep Medicine
Internal Medicine
Sports Medicine
Interventional Cardiology
Surgical Oncology
Interventional Pain Management
Thoracic Surgery
Interventional Radiology
Urology
Maxillofacial Surgery
Vascular Surgery
Medical Oncology
Undefined Physician Specialty
(Specify):
B. ELIGIBLE PROFESSIONAL OR OTHER NON-PHYSICIAN SPECIALTY TYPE
If you are an eligible professional (as defined in section 1848(K)(3)(B) of the Social Security Act), check the
appropriate box to indicate your specialty.
All individuals must meet specific licensing, certification, educational and work experience requirements. If you
need information concerning the specific requirements for your specialty, contact your designated MAC.
Check only one of the following:
Physician Assistant
Certified Nurse Midwife
Qualified Audiologist
Clinical Nurse Specialist
Qualified Speech-Language Pathologist
Clinical Psychologist
Registered Dietician or Nutritional Professional
Clinical Social Worker
Unlisted Practitioner Type
Nurse Practitioner
Occupational Therapist
(Specify):
Physical Therapist
CMS-855O (01/17)
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