Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 21

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SeCtion 4: PraCtiCe loCa tion inforMa tion
(Continued)
g. geographic location for Mobile or Portable Suppliers where the Base of operations and/or
Vehicle renders Services
Provide the city/town, State, and ZIP Code for all locations where mobile and/or portable services
are rendered.
If you provide mobile or portable health care services in more than one State and those States are
note:
serviced by different Medicare fee-for-service contractors, complete a separate enrollment application
(CMS-855B) for each Medicare fee-for-service contractor’s jurisdiction.
initial rePorting and/or additionS
If you are reporting or adding 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 services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
City/town
State
ZiP Code
deletionS
If you are 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 services you are deleting are furnished in selected cities/towns, provide 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)
20

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