Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 11

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SeCtion 2: identifying inforMation
(Continued)
C. hospitals only (Continued)
If your hospital is enrolling a clinic that is not provider-based, do not complete this section.
note:
Check
“Clinic/group Practice” in Section 2a and complete this entire application for the clinic.
1. Are you going to:
bill for the entire hospital with one billing number? (If yes, continue to Section 2D.)
separately bill for each hospital department? (If yes, answer Question 2.)
2. List the hospital departments for which you plan to bill separately:
dePartMent
MediCare identifiCation nuMBer
nPi
d. Comments/Special Circumstances
Explain any unique circumstances concerning your practice location, the method by which you render
health care services, etc.
e. Physical therapy (Pt) and occupational therapy (ot) groups only
1. Are all of the group’s PT/OT services rendered in patients’ homes or in the
YES
NO
group’s private office space?
2. Does this group maintain private office space?
YES
NO
3. Does this group own, lease, or rent its private office space?
YES
NO
4. Is this private office space used exclusively for the group’s private practice?
YES
NO
5. Does this group provide PT/OT services outside of its office and/or patients’ homes?
YES
NO
If you responded YES to any of the questions 2–5 above, submit a copy of the lease agreement that gives the
group exclusive use of the facilities for PT/OT services.
f. accreditation for ambulatory Surgical Centers (aSCs) only
Copy and complete this section if more than one accreditation needs to be reported.
note:
Check one of the following and furnish any additional information as requested:
The enrolling ASC supplier is accredited.
The enrolling ASC supplier is not accredited (includes exempt providers).
Name of Accrediting Organization
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration of Current Accreditation (mm/dd/yyyy)
CMS-855B (07/11)
10

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