Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 7

Download a blank fillable Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SeCtion 1: BaSiC inforMation
(Continued)
B. Check all that apply and complete the required sections:
reQuired SeCtionS
1, 2 (complete only those sections that are changing),
3, 13, and either 15 (if you are an authorized official)
Identifying Information
or 16 (if you are a delegated official), and 6 for the
signer if that authorized or delegated official has not
been established for this supplier
1, 2B1, 3, 13, and either 15 (if you are an authorized
official) or 16 (if you are a delegated official), and
Final Adverse Actions/Convictions
6 for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 4 (complete only those sections that are
changing), 13, and either 15 (if you are an authorized
Practice Location Information, Payment
Address & Medical Record Storage
official) or 16 (if you are a delegated official), and
Information
6 for the signer if that authorized or delegated official
has not been established for this supplier
Change of Ownership (Hospitals, Portable
Complete all sections and
X-Ray Suppliers & Ambulatory Surgical
provide a copy of the sales agreement
Centers Only)
1, 2B1, 3, 5, 13, and either 15 (if you are an authorized
official) or 16 (if you are a delegated official), and 6
Ownership Interest and/or Managing
Control Information (Organizations)
for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 6, 13, and either 15 (if you are an authorized
Ownership Interest and/or Managing Control
official) or 16 (if you are a delegated official), and 6
Information (Individuals)
for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 8 (complete only those sections that are
changing), 13, and either 15 (if you are an authorized
official) or 16 (if you are a delegated official), and 6
Billing Agency Information
for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 13, 15 or 16 (if you are a delegated
official), and 6 for the signer if that authorized or
Authorized Official(s)
delegated official has not been established for
this supplier
1, 2B1, 3, 13, 15, 16, and 6 for the signer if that
Delegated Official(s) (Optional)
delegated official has not been established for
this supplier.
CMS-855B (07/11)
6

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855a - Medicare Enrollment Application - Institutional Providers Form Cms-855a - Medicare Enrollment Application - Institutional Providers Medical
Form Cms-46 - Medicare Participating Physician And Supplier Agreement Form Cms-46 - Medicare Participating Physician And Supplier Agreement Legal
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical

Related Categories

Parent category: Medical
Download
Go
Page of 49