Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 8

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SECTION 1: BASIC INFORMATION
(Continued)
A. Check one box and complete the required sections
Former Organizations:
Your organization has
Medicare Identification Number of the
Consolidated with another
1A, 2H, 13, and either 15
Seller/Former Owner (if issued):
or 16
organization
New Organization:
You are the:
NPI:
Complete all sections
Former organization
except 2F and 2G
New organization
Tax Identification Number:
You are changing your Medicare
Go to Section 1B
Medicare Identification Number
(if issued):
information
NPI:
You are revalidating your
Complete all applicable
Enter your Medicare Identification
sections except 2F, 2G,
Medicare enrollment
Number (if issued) and the NPI you
and 2H
would like to link to this number in
Section 4.
CMS-855A (07/11)
7

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