Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 20

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SeCtion 4: PraCtiCe loCa tion inforMa tion
(Continued)
e. Base of operations address for Mobile or Portable Suppliers (location of Business office or
dispatcher/Scheduler)
The base of operations is the location from where personnel are dispatched, where mobile/portable
equipment is stored, and when applicable, where vehicles are parked when not in use.
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)
Check here
and skip to Section 4f if the “Base of operations” address is the same as the “Practice
location” listed in Section 4a.
Street Address Line 1 (Street Name and Number)
Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
f. Vehicle information
If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish
the following vehicle information. Do not provide information about vehicles that are used only to
transport medical equipment (e.g., when the equipment is transported in a van but is used in a fixed setting,
such as a doctor’s office) or ambulance vehicles. If more than two vehicles are used, copy and complete
this section as needed.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
tyPe of VehiCle
VehiCle
CheCk one for eaCh VehiCle
(van, mobile home, trailer, etc.)
identifiCation nuMBer
CHANGE
ADD
DELETE
Effective Date:
CHANGE
ADD
DELETE
Effective Date:
for each vehicle, submit a copy of all health care related permits/licenses/registrations.
CMS-855B (07/11)
19

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