Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 12

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SECTION 2: IDENTIFYING INFORMATION
(Continued)
G. Termination of Physician Assistants (Only)
Complete this section to delete employed physician assistants from your group or clinic.
PHYSICIAN ASSISTANT’S
EFFECTIVE DATE
PHYSICIAN ASSISTANT’S
PHYSICIAN ASSISTANT’S
MEDICARE IDENTIFICATION
OF DEPARTURE
NAME
NPI
NUMBER
H. Advanced Diagnostic Imaging (ADI) Suppliers Only
This section must be completed by all suppliers that also furnish and will bill Medicare for ADI services.
All suppliers furnishing ADI services MUST be accredited in each ADI Modality checked below to qualify
to bill Medicare for those services.
Check each ADI modality this supplier will furnish and the name of the Accrediting Organization that
accredited that ADI Modality for this supplier.
Magnetic Resonance Imaging (MRI)
Name of Accrediting Organization for MRI
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
Computed Tomography (CT)
Name of Accrediting Organization for CT
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
Nuclear Medicine (NM)
Name of Accrediting Organization for NM
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
Positron Emission Tomography (PET)
Name of Accrediting Organization for PET
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
CMS-855B (07/11)
11

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