Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 13

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SECTION 2: IDENTIFYING INFORMATION
(Continued)
2. STATE LICENSE INFORMATION/CERTIFICATION INFORMATION
Provide the following information if the provider has a State license/certification to operate as the provider
type for which you are enrolling.
State License Not Applicable
License Number
State Where Issued
Effective Date (mm/dd/yyyy)
Expiration/Renewal Date (mm/dd/yyyy)
Certification Information
Certification Not Applicable
Certification Number
State Where Issued
Effective Date (mm/dd/yyyy)
Expiration/Renewal Date (mm/dd/yyyy)
C. Correspondence Address
Provide contact information for the entity listed in Section 2B1 of this section. Once enrolled, the
information provided below will be used by the fee-for-service contractor if it needs to contact you
directly. This address cannot be a billing agency’s
address.
Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
D. Accreditation
Is this provider accredited?
YES
NO
If YES, complete the following:
Date of Accreditation (mm/dd/yyyy)
Expiration Date of Accreditation (mm/dd/yyyy)
Name of Accrediting Body
Type of Accreditation or Accreditation Program (e.g., hospital accreditation program, home health accreditation, etc.)
E. Comments
Use this section to clarify any information furnished in this section.
CMS-855A (07/11)
12

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