Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 18

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SECtion 4: PraCtiCE loCation inforMation
(Continued)
d. rendering Services in Patients’ homes
List the city/town, State, and ZIP code for all locations where health care services are rendered in patients’
homes. If you provide health care services in more than one State and those States are serviced by different
Medicare fee-for-service contractors, complete a separate enrollment application (CMS-855I) for each
Medicare fee-for-service contractor’s jurisdiction.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
ChECK onE
ChangE
add
dElEtE
datE
(mm/dd/yyyy)
initial rEPorting and/or additionS
If you are reporting or adding an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.
Entire State of __________________________
If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
City/town
StatE
ZiP CodE
dElEtionS
If you are deleting an entire State, it is not necessary to report each city/town. Simply check the box below
and specify the State.
Entire State of __________________________
If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are
not servicing the entire city/town.
City/town
StatE
ZiP CodE
CMS-855I (07/11)
17

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