Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 18

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SeCtion 4: PraCtiCe loCa tion inforMa tion
(Continued)
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
first Medical record Storage facility (for current and former patients)
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Second Medical record Storage facility (for current and former patients)
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
CMS-855B (07/11)
17

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