Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 45

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attaChMent 2: indePendent diagnoStiC teSting f aCilitieS
(Continued)
3
interpreting Physician information
rd
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)
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Social Security Number (Required)
Date of Birth (mm/dd/yyyy) (Required)
Medicare Identification Number (if issued)
NPI
d. Personnel (technicians) who Perform tests
Complete this section with information about all non-physician personnel who perform tests for this IDTF.
Notarized or certified true copies of the State license or certificate should be attached.
1
PerSonnel (teChniCian) inforMation
St
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)
First Name
Middle Initial
Last Name
Suffix (e.g., Jr., Sr.)
Social Security Number (Required)
Date of Birth (mm/dd/yyyy) (Required)
Is this technician State licensed or State certified? (see instructions for clarification)
YES
NO
License/Certification Number (if applicable)
License/Certification Issue Date (mm/dd/yyyy) (if applicable)
Is this technician certified by a national credentialing organization?
YES
NO
Name of credentialing organization (if applicable)
Type of Credentials (if applicable)
Is this technician employed by a hospital?
YES
NO
If yeS, provide the name of the hospital here: ________________________________________
CMS-855B (07/11)
44

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