Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 2

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Form Approved OMB
No. 0938-0685
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Expires: 08/19
CENTERS FOR MEDICARE & MEDICAID SERVICES
who Should CoMPlEtE thiS aPPliCation
Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a
change in their enrollment information using either:
•
The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
•
The paper enrollment application process (e.g., CMS 855I).
For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go
to
Physicians and non-physician practitioners who are enrolled in the Medicare program, but have not
submitted the CMS 855I since 2003, are required to submit a Medicare enrollment application (i.e.,
Internet-based PECOS or the CMS 855I) as an initial application when reporting a change for the first time.
All physicians, as well as all non-physician practitioners listed below, must complete this application to
initiate the enrollment process:
Anesthesiology Assistant
Mass immunization roster biller
Psychologist, Clinical
Audiologist
Nurse practitioner
Psychologist billing
Certified nurse midwife
Occupational therapist in
independently
Certified registered nurse
private practice
Registered Dietitian or
anesthetist
Physical therapist in
Nutrition Professional
Clinical nurse specialist
private practice
Speech Language Pathologist
Clinical social worker
Physician assistant
If your supplier type is not listed above, contact your designated fee-for-service contractor before you
submit this application.
Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
•
An individual practitioner who will provide services in a private setting.
•
An individual practitioner who will provide services in a group setting. If you plan to render all of
your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17
of this application.
•
Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-
service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory
serviced by another Medicare fee-for-service contractor).
•
Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you
have added or changed a practice location).
•
An individual who has formed a professional corporation, professional association, limited liability
company, etc., of which you are the sole owner.
If you provide services in a group/organization setting, you will also need to complete a separate
application, the CMS-855R, to reassign your benefits to each organization. If you terminate your
association with an organization, use the CMS-855R to submit that change.
CMS-855I (07/11)
1

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