Form Cms-8550 - Medicare Enrollment Application Page 7

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SECTION 5: IMPORTANT ADDRESS INFORMATION
CORRESPONDENCE MAILING ADDRESS
Once you are enrolled, the MAC will use the address and contact information in this section if it needs to
contact you directly.
Business Location Name
Attention (optional)
Mailing Address Line 1 (P.O. Box or Street Name and Number)
Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
SECTION 6: CONTACT PERSON INFORMATION (Optional)
If questions arise during the processing of only this application, your designated MAC will attempt to contact
the individual you list in this section. All other inquiries will be directed to the contact listed in section 5.
First Name
Middle Initial
Last Name
Jr., Sr., MD., etc.
Address Line 1 (P.O. Box or Street Name and Number)
Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
Relationship or Affiliation to You
NOTE:
During the enrollment process, the MAC may request documentation to support and validate
information reported on this application. You must provide this documentation in a timely manner.
CMS-855O (01/17)
6

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