Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 38

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attaChMent 1: aMBulanCe SerViCe SuPPlierS
(Continued)
B. State license information
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
Crew members must complete continuing education requirements in accordance with State and local
licensing laws. Evidence of re-certification must be retained with the employer in case it is required by the
Medicare fee-for-service contractor.
CheCk one
Change
add
delete
date
(mm/dd/yyyy)
Is this ambulance company licensed in the State where services are rendered and billed for?
YES
NO
If no, explain why:
If yeS, provide the license information for the State where this ambulance service supplier will be rendering
services and billing Medicare. Attach a copy of the current State license.
License Number
Issuing State (if applicable)
Issuing City/Town (if applicable)
Effective Date (mm/dd/yyyy)
Expiration Date (mm/dd/yyyy)
C. Paramedic intercept Services information
Paramedic Intercept Services involve an arrangement between a Basic Life Support (BLS) ambulance
company and an Advanced Life Support (ALS) ambulance company whereby the latter provides the ALS
services and the BLS ambulance company provides the transportation component. If such an arrangement
exists between the enrolling ambulance company and another ambulance company, the enrolling
ambulance company must attach a copy of the signed contract. For more information, see 42 C.F.R.
410.40.
If reporting a change to information about a previously reported agreement/contract, check “Change” and
provide the effective date of the change.
Change
Effective Date:__________________________
Does this ambulance company currently participate in a paramedic intercept services arrangement?
YES
NO
CMS-855B (07/11)
37

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