Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 15

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SeCtion 4: PraCtiCe loCa tion inforMa tion
inStruCtionS
This section captures information about the physical location(s) where you currently provide health care
services. If you operate a mobile facility or portable unit, provide the address for the “Base of Operations,”
as well as vehicle information and the geographic area serviced by these facilities or units.
Only report those practice locations within the jurisdiction of the Medicare fee-for-service contractor to
which you will submit this application. If you have practice locations in another Medicare fee-for-service
contractor’s jurisdiction, complete a separate enrollment application (CMS-855B) for those practice
locations and submit it to the Medicare fee-for-service contractor that has jurisdiction over those locations.
Provide the specific street address as recorded by the United States Postal Service. Do not provide a P.O.
Box. If you provide services in a hospital and/or other health care facility for which you bill Medicare
directly for the services rendered at that facility, provide the name and address of the hospital or facility.
MoBile faCility and/or PortaBle unit
A “mobile facility” is generally a mobile home, trailer, or other large vehicle that has been converted,
equipped, and licensed to render health care services. These vehicles usually travel to local shopping
centers or community centers to see and treat patients inside the vehicle.
A “portable unit” is when the supplier transports medical equipment to a fixed location (e.g., physician’s
office, nursing home) to render services to the patient.
The most common types of mobile facilities/portable units are mobile IDTFs, portable X-ray suppliers,
portable mammography, and mobile clinics. Physicians and non-physician practitioners (e.g., nurse
practitioners, physician assistants) who perform services at multiple locations (e.g., house calls, assisted
living facilities) are not considered to be mobile facilities/portable units.
CMS-855B (07/11)
14

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