Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 16

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SECTION 2: IDENTIFYING INFORMATION
(Continued)
Provide the name and Medicare identification number of all units of the above provider that have separate
Medicare identification numbers but have not entered into separate provider agreements, such as swing-bed
units of a hospital and HHA branches. Also furnish the NPI. Units that already have a separate provider
agreement should not be reported here.
MEDICARE IDENTIFICATION
NATIONAL PROVIDER
NAME/DEPARTMENT
NUMBER (IF ISSUED)
IDENTIFIER
3. NEWLY CREATED PROVIDER IDENTIFICATION INFORMATION
Complete this section with identifying information about the newly created provider resulting from this
consolidation.
Legal Business Name of the New Provider as Reported to the Internal Revenue Service
Tax Identification Number
Submit one copy of the bill of sale with the application. A copy of the final sales agreement must be
submitted once the sale is executed.
CMS-855A (07/11)
15

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