Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 25
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54SECTION 4: PRACTICE LOCATION INFORMATION
(Continued)
2. DELETIONS
If you are deleting 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)
24
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