Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 45

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SECTION 13: CONTACT PERSON
If questions arise during the processing of this application, the fee-for-service contractor will contact the
individual shown below. If the contact person is an authorized or delegated official, check the appropriate
box below and skip to the section indicated.
Contact an Authorized Official listed in Section 15
Contact a Delegated Official listed in Section 16
First Name
Middle Initial Last Name
Jr., Sr., etc.
Telephone Number
Fax Number (if applicable)
Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
E-mail Address
CMS-855A (07/11)
44

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