Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Page 9

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SECTION 2: IdENTIfyINg INfOrmaTION
a. Type of Supplier
Check the appropriate box to identify the type of supplier you are enrolling as with Medicare. If you are
more than one type of supplier, submit a separate application for each type. If you change the type of
service that you provide (i.e., become a different supplier type), submit a new application.
Your organization must meet all Federal and State requirements for the type of supplier checked below.
TypE Of SupplIEr:
(Check one only)
Ambulance Service Supplier
Mass Immunization (Roster Biller Only)
Ambulatory Surgical Center
Pharmacy
Clinic/Group Practice
Physical/Occupational Therapy Group in
Private Practice
Hospital Department(s)
Portable X-ray Supplier
Independent Clinical Laboratory
Radiation Therapy Center
Independent Diagnostic Testing Facility
Other (Specify):
Intensive Cardiac Rehabilitation
________________________________
Mammography Center
B. Supplier Identification Information
1. BuSINESS INfOrmaTION
Legal Business Name (not the “Doing Business As” name) as reported to the Internal Revenue Service
Tax Identification Number
Other Name
Type of Other Name
Former Legal Business Name
Doing Business As Name
Other (Specify): _________________________
Identify how your business is registered with the IRS. (NOTE: If your business is a Federal and/or State
government provider or supplier, indicate “Non-Profit” below.)
Proprietary
Non-Profit
NOTE: If a checkbox indicating Proprietary or non-profit status is not completed, the provider/supplier will be
defaulted to “Proprietary.”
Identify the type of organizational structure of this provider/supplier (Check one)
Corporation
Limited Liability Company
Partnership
Sole Proprietor
Other (Specify):
_______________________
Incorporation Date (mm/dd/yyyy) (if applicable)
State Where Incorporated (if applicable)
Is this supplier an Indian Health Facility enrolling with the designated Indian Health Service (IHS) Medicare
Administrative Contractor (MAC)?
Yes
No
CMS-855B (07/11)
8

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