Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 6

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SECTION 1: BASIC INFORMATION
(Continued)
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 changing your
Go to Section 1B
Medicare Identification Number:
Medicare information
National Provider Identifier (if issued):
Enter your Medicare Identification
You are revalidating your
Complete all applicable
Number
and the NPI you
sections
Medicare enrollment
(if issued)
would like to link to this number in
Ambulance suppliers must
Section 4.
complete Attachment 1
IDTF suppliers must complete
Attachment 2
CMS-855B (07/11)
5

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