Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 23

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SECTION 4: PRACTICE LOCATION INFORMATION
(Continued)
Second 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
D. Base of Operations Address for Mobile or Portable Providers (Location of Business Office or
Dispatcher/Scheduler)
The base of operations is the location from where personnel are dispatched, where mobile/portable
equipment is stored, and when applicable, where vehicles are parked when not in use.
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)
Check here
and skip to Section 4E if the “Base of Operations” address is the same as the
“Practice Location” listed in Section 4A.
Street Address Line 1 (Street Name and Number)
Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
CMS-855A (07/11)
22

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