Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 42

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SECTION 8: BILLING AGENCY INFORMATION
Applicants that use a billing agency must complete this section. A billing agency is a company or
individual that you contract with to process and submit your claims. If you use a billing agency, you are
responsible for the claims submitted on your behalf.
Check here if this section does not apply and skip to Section 12.
BILLING AGENCY NAME AND ADDRESS
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)
Legal Business/Individual Name as Reported to the Social Security Administration or Internal Revenue Service
If Individual, Billing Agent Date of Birth (mm/dd/yyyy)
Tax Identification Number or Social Security Number (required)
“Doing Business As” Name (if applicable)
Billing Agency Address Line 1 (Street Name and Number)
Billing Agency Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
SECTION 9: FOR FUTURE USE
(THIS SECTION NOT APPLICABLE)
SECTION 10: FOR FUTURE USE
(THIS SECTION NOT APPLICABLE)
SECTION 11: FOR FUTURE USE
(THIS SECTION NOT APPLICABLE)
CMS-855A (07/11)
41

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