Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 24

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SECTION 4: PRACTICE LOCATION INFORMATION
(Continued)
E. Vehicle Information
If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish
the following vehicle information. Do not furnish information about ambulance vehicles, or vehicles that
are used only to transport medical equipment (e.g., when the equipment is transported in a van but is used
in a fixed setting, such as a doctor’s office). If more than three vehicles are used, copy and complete this
section as needed.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
VEHICLE
TYPE OF VEHICLE
CHECk ONE FOR EACH VEHICLE
(van, mobile home, trailer, etc.)
IDENTIFICATION NUMBER
CHANGE
ADD
DELETE
Effective Date:
CHANGE
ADD
DELETE
Effective Date:
CHANGE
ADD
DELETE
Effective Date:
For each vehicle, submit a copy of all health care related permits/licenses/registrations.
F. Geographic Location For Mobile or Portable Providers where the Base of Operations and/or
Vehicle Renders Services
For home health agencies (HHAs) and mobile/portable providers, furnish information identifying the
geographic area(s) where health care services are rendered.
If you provide mobile health care services in more than one State and those States are serviced by
NOTE:
different Medicare fee-for-service contractors, complete a separate enrollment application (CMS-855A) for
each Medicare fee-for-service contractor’s jurisdiction.
1. INITIAL REPORTING AND/OR ADDITIONS
If you are reporting or adding an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.
Entire State of __________________________
If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
CITY/TOWN
STATE
ZIP CODE
CMS-855A (07/11)
23

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