Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 28

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SeCtion 7: for future uSe (thiS SeCtion not aPPliCaBle)
SeCtion 8: Billing agenCy inforMa tion
A billing agency is a company or individual that you contract with to prepare and submit your claims. If
you use a billing agency, you are responsible for the claims submitted on your behalf.
Check here if this section does not apply and skip to Section 13.
Billing agenCy naMe and addreSS
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)
Legal Business/Individual Name as Reported to the Social Security
If Individual, Billing Agent Date of Birth
Administration or the Internal Revenue Service
(mm/dd/yyyy)
“Doing Business As” Name (if applicable)
Tax Identification/Social Security Number (required)
Billing Agency Street Address Line 1 (Street Name and Number)
Billing Agency Street Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
SeCtion 9: for future uSe (thiS SeCtion not aPPliCaBle)
SeCtion 10: for future uSe (thiS SeCtion not aPPliCaBle)
SeCtion 11: for future uSe (thiS SeCtion not aPPliCaBle)
SeCtion 12: for future uSe (thiS SeCtion not aPPliCaBle)
CMS-855B (07/11)
27

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