Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 8

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SeCtion 1: BaSiC inforMation
(Continued)
attaChMent 1: aMBulanCe SerViCe SuPPlierS (only)
reQuired SeCtionS
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Geographic Area
delegated official
Attachment 1(A)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
State License Information
delegated official
Attachment 1(B)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Paramedic Intercept Services Information
delegated official
Attachment 1(C)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Vehicle Information
delegated official
Attachment 1(D)
attaChMent 2: indePendent diagnoStiC teSting
reQuired SeCtionS
faCilitieS (only)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
CPT-4 and HCPCS Codes
delegated official
Attachment 2(B)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Interpreting Physician Information
delegated official
Attachment 2(C)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Personnel (Technicians) Who Perform Tests
delegated official
Attachment 2(D)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Supervising Physician(s)
delegated official
Attachment 2(E)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Liability Insurance Information
delegated official
Attachment 2(F)
CMS-855B (07/11)
7

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