Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 5

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SeCtion 1: BaSiC inforMation
all aPPliCantS MuSt CoMPlete thiS SeCtion
(See instructions for details.)
a. Check one box and complete the required sections.
reaSon for aPPliCation
Billing nuMBer inforMation
reQuired SeCtionS
You are a new enrollee in
Enter your Medicare Identification
Complete all applicable
Medicare
Number
and the NPI you
sections
(if issued)
would like to link to this number in
Ambulance suppliers must
Section 4.
complete Attachment 1
IDTF suppliers must complete
Attachment 2
You are enrolling in
Complete all applicable
Enter your Medicare Identification
another fee-for-service
Number
and the NPI you
sections
(if issued)
contractor’s jurisdiction
would like to link to this number in
Ambulance suppliers must
Section 4.
complete Attachment 1
IDTF suppliers must complete
Attachment 2
You are reactivating your
Enter your Medicare Identification
Complete all applicable
sections
Medicare enrollment
Number
and the NPI you
(if issued)
would like to link to this number in
Ambulance suppliers must
Section 4.
complete Attachment 1
IDTF suppliers must complete
Medicare Identification Number(s)
(if issued):
Attachment 2
National Provider Identifier (if issued):
You are voluntarily
Sections 1, 2B1, 13, and either
Effective Date of Termination:
terminating your
15 or 16
Medicare enrollment. (This
If you are terminating an
Medicare Identification Number(s) to
is not the same as “opting
Terminate (if issued):
employment arrangement
out” of the program)
with a physician assistant,
complete Sections 1A, 2G, 13,
National Provider Identifier (if issued):
and either 15 or 16
CMS-855B (07/11)
4

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