Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 16

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SECtion 4: PraCtiCE loCation inforMation
(Continued)
1. If you are reassigning all of your payments to another group or organization furnish the name,
Medicare identification number(s) and NPI of each group or organization below and proceed to
Section 13.
2. If any of your payments are part of your private practice and a group or organization furnish the name
and Medicare identification number(s) and NPI of each group or organization below and continue to
Section 4C (where you will enter your private practice information).
3. If you are not reassigning all or any of your payments to another group or organization, skip to
Section 4C with information about your private practice.
a) Name of Group/Organization
Medicare Identification Number (if issued) National Provider Identifier
b) Name of Group/Organization
Medicare Identification Number (if issued) National Provider Identifier
c) Name of Group/Organization
Medicare Identification Number (if issued) National Provider Identifier
d) Name of Group/Organization
Medicare Identification Number (if issued) National Provider Identifier
e) Name of Group/Organization
Medicare Identification Number (if issued) National Provider Identifier
C. Practice location information
• If you completed Section 4A, complete Section 4C through Section 17 for your business.
• All locations disclosed on claims forms should be identified in this section as practice locations.
• Complete this section for each of your practice locations where you render services to Medicare
beneficiaries.
However, you should only report those practice locations within the jurisdiction of the Medicare
fee-for-service contractor to which you will submit this application. If you render services in a hospital
and/or other health care facility, furnish the name and address of that hospital or facility.
• Each practice location must be a specific street address as recorded by the United States Postal
Service. Do not report a P.O. Box.
• If you only render services in patients’ homes (house calls), you may supply your home address in this
section if you do not have an office. In Section 4H, explain that this address is for administrative
purposes only and that all services are rendered in patients’ homes.
• If you render services in a retirement or assisted living community, complete this section with the
names, telephone numbers and addresses of those communities.
If you have a CLIA number and/or FDA/Radiology Certification Number for this practice location,
provide that information and submit a copy of the most current CLIA and FDA certification for each
practice location reported.
CMS-855I (07/11)
15

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