Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 4

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ADDITIONAL INFORMATION
For additional information regarding the Medicare enrollment process, visit
MedicareProviderSupEnroll.
The fee-for-service contractor may request, at any time during the enrollment process, documentation
to support or validate information reported on the application. You are responsible for providing this
documentation in a timely manner.
The information you provide on this application will not be shared. It is protected under 5 U.S.C. Section
552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the
Privacy Act Statement.
MAIL YOUR APPLICATION
The Medicare fee-for-service contractor (also referred to as a fiscal intermediary or a Medicare
administrative contractor) that services your State is responsible for processing your enrollment
application. To locate the mailing address for your fee-for-service contractor, go to
MedicareProviderSupEnroll.
CMS-855A (07/11)
3

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