Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 7
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54SECTION 1: BASIC INFORMATION
(Continued)
A. Check one box and complete the required sections
REASON FOR APPLICATION
BILLING NUMBER INFORMATION
REQUIRED SECTIONS
You are a new enrollee in
Enter your Medicare Identification
Complete all applicable
sections except 2F, 2G,
Medicare
Number (if issued) and the NPI you
and 2H
would like to link to this number in
Section 4.
Complete all applicable
Enter your Medicare Identification
You are enrolling with another fee-
sections except 2F, 2G,
for-service contractor’s jurisdiction
Number (if issued) and the NPI you
and 2H
would like to link to this number in
You are reactivating your
Section 4.
Medicare enrollment
You are voluntarily terminating
Complete sections:
Effective Date of Termination:
1, 2B1, 13, and either 15
your Medicare enrollment
or 16
Medicare Identification Number(s) to
Terminate (if issued):
National Provider Identifier (if issued):
There has been a Change of
Seller/Former Owner: 1A,
Tax Identification Number:
Ownership (CHOW) of the
2F, 13, and either 15 or 16
Medicare-enrolled provider
Buyer/New Owner:
Complete all sections
You are the:
except 2G and 2H
Seller/Former Owner
Buyer/New Owner
Seller/Former Owner: 1A,
Your organization has taken part in
Medicare Identification Number of the
an Acquisition or Merger
2G, 13, and either 15 or 16
Seller/Former Owner (if issued):
Buyer/New Owner:
You are the:
1A, 2G, 4, 13, and either 15
Seller/Former Owner
NPI:
Buyer/New Owner
(if you are the authorized
official) or 16 (if you are the
Tax Identification Number:
delegated official), and 6 for
the signer if that authorized
or delegated official has not
been established for this
provider.
CMS-855A (07/11)
6
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