Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 19

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SeCtion 4: PraCtiCe loCa tion inforMa tion
(Continued)
d. rendering Services in Patients’ homes
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)
Furnish the city/town, State and ZIP code for all locations where health care services are rendered in
patients’ homes. If you provide health care services in more than one State and those States are serviced by
different Medicare fee-for-service contractors, complete a separate CMS-855B enrollment application for
each Medicare fee-for-service contractor’s jurisdiction.
If you are adding or deleting an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.
Entire State of __________________________
If you are providing services in selected cities/towns, furnish the locations below. Only list ZIP codes if
you are not servicing the entire city/town.
City/town
State
ZiP Code
CMS-855B (07/11)
18

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