Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 22

Download a blank fillable Form Cms-855a - Medicare Enrollment Application - Institutional Providers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855a - Medicare Enrollment Application - Institutional Providers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECTION 4: PRACTICE LOCATION INFORMATION
(Continued)
B. Where Do You Want Remittance Notices Or Special Payments Sent?
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CHECk ONE
CHANGE
ADD
DELETE
DATE
(mm/dd/yyyy)
Medicare will issue payments via electronic funds transfer (EFT). Since payment will be made by EFT,
the “Special Payments” address will indicate where all other payment information (e.g., remittance notices,
special payments) are sent.
“Special Payments” address is the same as the practice location (only one address is listed in Section
4A). Skip to Section 4C.
“Special Payments” address is different than that listed in Section 4A, or multiple locations are listed.
Provide address below.
“Special Payments” Address Line 1 (PO Box or Street Name and Number)
“Special Payments” Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
C. Where Do You keep Patients’ Medical Records?
If you store patients’ medical records (current and/or former patients) at a location other than the location
in Section 4A or 4D, complete this section with the address of the storage location.
If this
section is not complete, you are indicating that all records are stored at the practice locations
reported in Section 4A or 4D. The records must be the provider’s records, not the records of another
provider. Post Office Boxes and drop boxes are not acceptable as physical addresses where patients’
records are maintained.
For mobile facilities/portable units, the patients’ medical records must be under the provider’s control.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
First Medical Record Storage Facility for Current and Former Patients
CHECk ONE
CHANGE
ADD
DELETE
DATE
(mm/dd/yyyy)
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
CMS-855A (07/11)
21

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Medical
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical
Form Cms-10069 - Medicare Waiver Demonstration Application Form Cms-10069 - Medicare Waiver Demonstration Application Medical
Medicare Enrolment Application Form Medicare Enrolment Application Form Medical
Form Cms-838 Medicare Credit Balance Report Certification Page Form Cms-838 Medicare Credit Balance Report Certification Page Medical

Related Categories

Parent category: Medical
Download
Go
Page of 54