Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 4

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SeCtion 1: BaSiC inforMation
new enrolleeS and thoSe with a new tax id nuMBer
If you are:
• Enrolling in the Medicare program for the first time with this Medicare fee-for-service contractor under
this tax identification number.
• Already enrolled with a Medicare fee-for-service contractor but are establishing a practice location in
another fee-for-service contractor’s jurisdiction.
• Enrolled with a Medicare fee-for-service contractor but have a new tax identification number. If you
are reporting a change to your tax identification number, you must complete a new application.
• A hospital or an individual hospital department that is enrolling with a fee-for-service contractor to bill
for Part B services.
The following actions apply to Medicare suppliers already enrolled in the program:
enrolled MediCare SuPPlierS
reactivation
To reactivate your Medicare billing privileges, submit this enrollment application. In addition, prior to
being reactivated, you must be able to submit a valid claim and meet all current requirements for your
supplier type before reactivation may occur.
Voluntary termination
A supplier should voluntarily terminate its Medicare enrollment when it:
• Will no longer be rendering services to Medicare patients, or
• Is planning to cease (or has ceased) operations.
Change of ownership
If a hospital, ambulatory surgical center, or portable X-ray supplier is undergoing a change of ownership
(CHOW) in accordance with the principles outlined in 42 C.F.R. 489.18, the entity must submit a new
application for the new ownership.
Change of information
A change of information should be submitted if you are changing, adding or deleting information under
your current tax identification number.
Changes in your existing enrollment data must be reported to the fee-for-service contractor in accordance
with 42 C.F.R. § 424.516 (Physician and Non Physician Practitioner Organizations). (IDTF changes of
information must comply with the provisions found at 42 C.F.R. § 410.33.)
If you are already enrolled in Medicare and are not receiving Medicare payments via EFT, any
change to your enrollment information will require you to submit a CMS-588 form. All future
payments will then be made via EFT.
revalidation
CMS may require you to submit or update your enrollment information. The fee-for-service contractor will
notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation
application until you have been contacted by the fee-for-service contractor.
CMS-855B (07/11)
3

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