Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 37

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attaChMent 1: aMBulanCe SerViCe SuPPlierS
All ambulance service suppliers enrolling in the Medicare program must complete this attachment.
a. geographic area
This section is to be completed with information about the geographic area in which this company
provides ambulance services. If you are changing, adding, or deleting information, check the applicable
box, furnish the effective date, and complete the appropriate fields in this section.
Provide the city/town, State, and ZIP code for all locations where this ambulance company renders
services.
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
If the ambulance company has vehicles garaged within a different Medicare contractor’s
note:
jurisdiction, a separate CMS-855B enrollment application must be submitted to that fee-for-service
contractor.
1. initial rePorting and/or additionS
If services are provided in selected cities/towns, provide the locations below. List ZIP codes only if they
are not within the entire city/town.
City/town
State
ZiP Code
2. deletionS
If services are no longer provided in selected cities/towns, provide the locations below. List ZIP codes only
if they are not within the entire city/town.
City/town
State
ZiP Code
CMS-855B (07/11)
36

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