Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 27

Download a blank fillable Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECtion 15: CErtifiCation StatEMEnt
(Continued)
First Name
Middle Initial Last Name
M.D., D.O., etc.
Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
Date Signed (mm/dd/yyyy)
all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed not original will
not be processed. Stamped, faxed or copied signatures will not be accepted.
SECtion 16: for futurE uSE (thiS SECtion not aPPliCablE)
SECtion 17: SuPPorting doCuMEntS
This section lists the documents that, if applicable, must be submitted with this enrollment
application. For changes, only submit documents that are applicable to the change requested. The
fee-for-service contractor may request, at any time during the enrollment process, documentation to
support or validate information reported on the application. In addition, the Medicare fee-for-service
contractor may also request documents from you, other than those identified in this section 17, as are
necessary to bill Medicare.
Mandatory for all ProvidEr/SuPPliEr tyPES
Completed Form CMS-588, for Electronic Funds Transfer Authorization Agreement.
If a supplier already receives payments electronically and is not making a change to his/her
notE:
banking information, the CMS-588 is not required. (Moreover, physicians and non-physician
practitioners who are reassigning all of their payments to another entity are not required to submit the
CMS-588.)
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business
Name (e.g., IRS form CP 575) provided in Section 2. (
This information is needed if the applicant
notE:
is enrolling their professional corporation, professional association, or limited liability corporation with
this application or enrolling as a sole proprietor using an Employer Identification Number.)
Mandatory, if aPPliCablE
Copy of IRS Determination Letter, if provider is registered with the IRS as non-profit.
Copy(s) of all final adverse action documentation (e.g., notifications, resolutions, and
reinstatement letters).
Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.
Completed Form CMS-855R, Individual Reassignment of Medicare Benefits.
Statement in writing from the bank. If Medicare payment due a supplier of services is being sent to a
bank (or similar financial institution) where the supplier has a lending relationship (that is, any type of
loan), then the supplier must provide a statement in writing from the bank (which must be in the loan
agreement) that the bank has agreed to waive its right of offset for Medicare receivables.
Written confirmation from the IRS confirming your Limited Liability Company (LLC) is automatically
classified as a Disregarded Entity (e.g., Form 8832). (
A disregarded entity is an eligible entity
notE:
that is treated as an entity not separate from its single owner for income tax purposes.)
Copy of current CLIA and FDA certification for each practice location reported.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete
this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance
Officer, Baltimore, Maryland 21244-1850.
do not Mail aPPliCationS to thiS addrESS. Mailing your application to this address will significantly delay application processing.
CMS-855I (07/11)
26

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Medical
Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers Medical
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers Medical
Form Cms-8550 - Medicare Enrollment Application Form Cms-8550 - Medicare Enrollment Application Medical
Form Cms-855a - Medicare Enrollment Application - Institutional Providers Form Cms-855a - Medicare Enrollment Application - Institutional Providers Medical
Form Cms-46 - Medicare Participating Physician And Supplier Agreement Form Cms-46 - Medicare Participating Physician And Supplier Agreement Legal
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Form Cms-460 - Medicare Participating Physician Or Supplier Agreement Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc. Medical
Form Cms-671 - Ltc Facility Application For Medicare/medicaid Form Cms-671 - Ltc Facility Application For Medicare/medicaid Medical

Related Categories

Parent category: Medical
Download
Go
Page of 28