Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 16

Download a blank fillable Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SeCtion 4: PraCtiCe loCa tion inforMa tion
(Continued)
a. Practice location information
If you see patients in more than one practice location, copy and complete Section 4A for each location.
To ensure that CMS establishes the correct association between your Medicare legacy number and your
NPI, providers and suppliers must list a Medicare legacy number—NPI combination for each practice
location. If you have multiple NPIs associated with both a single legacy number and a single practice
location, please list below all NPIs and associated legacy numbers for that practice location.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
if you are enrolling for the first time, or if you are adding a new practice location, the date
you provide should be the date you saw your first Medicare patient at this location.
Practice Location Name (“Doing Business As” name if different from Legal Business Name)
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)
Practice Location Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
Date you saw your first Medicare patient at this practice location (mm/dd/yyyy)
Medicare Identification Number (if issued)
National Provider Identifier
Medicare Identification Number (if issued)
National Provider Identifier
Medicare Identification Number (if issued)
National Provider Identifier
Medicare Identification Number (if issued)
National Provider Identifier
Medicare Identification Number (if issued)
National Provider Identifier
Is this practice location a:
Group practice office/clinic
Skilled Nursing Facility and/or Nursing Facility
Hospital
Other health care facility
Retirement/assisted living community
(Specify):______________________________
CLIA Number for this location (if applicable)
Attach a copy of the most current CLIA certifications for each of the practice locations reported on this application
FDA/Radiology (Mammography) Certification Number for this location (if issued)
Attach a copy of the most current FDA certifications for each of the practice locations reported on this application.
CMS-855B (07/11)
15

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855a - Medicare Enrollment Application - Institutional Providers Form Cms-855a - Medicare Enrollment Application - Institutional Providers Medical
Form Cms-46 - Medicare Participating Physician And Supplier Agreement Form Cms-46 - Medicare Participating Physician And Supplier Agreement Legal
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical

Related Categories

Parent category: Medical
Download
Go
Page of 49