Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 12

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SECtion 2: idEntifying inforMation
(Continued)
l. advanced diagnostic imaging (adi) Suppliers only
This section must be completed by all individual practitioners that also furnish and will bill Medicare
for ADI services. All individual practitioners furnishing ADI services MUST be accredited in each ADI
Modality checked below to qualify to bill Medicare for those services.
Check each ADI Modality that you will furnish and the name of the Accrediting Organization that
accredited you for that ADI Modality.
Magnetic resonance imaging (Mri)
Name of Accrediting Organization for MRI
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
Computed tomography (Ct)
Name of Accrediting Organization for CT
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
nuclear Medicine (nM)
Name of Accrediting Organization for NM
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
Positron Emission tomography (PEt)
Name of Accrediting Organization for PET
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
CMS-855I (07/11)
11

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