Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 3

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billing nuMbEr inforMation
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and
is assigned by the National Plan and Provider Enumeration System (NPPES). As a Medicare healthcare
supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change to your
existing Medicare enrollment information. Applying for the NPI is a process separate from Medicare
enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.gov. For more information about
NPI enumeration, visit
The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN)
or Medicare Legacy Number, is a generic term for any number other than the NPI that is used to identify a
Medicare supplier.
inStruCtionS for CoMPlEting and SubMitting thiS aPPliCation
Type or print all information so that it is legible. Do not use pencil.
• Report additional information within a section by copying and completing that section for each
additional entry.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your own records.
• Send the completed application with original signatures and all required documentation to your
designated fee-for-service contractor.
avoid dElayS in your EnrollMEnt
To avoid delays in the enrollment process, you should:
• Complete all required sections.
• Ensure that the correspondence address shown in Section 2 is the supplier’s address.
• Enter your NPI in the applicable sections.
• Enter all applicable dates.
• Send the completed application with all supporting documentation to your designated
fee-for-service contractor.
additional inforMa tion
For additional information regarding the Medicare enrollment process, visit
MedicareProviderSupEnroll.
The fee-for-service contractor may request, at any time during the enrollment process, documentation to
support and validate information reported on the application. You are responsible for providing this
documentation in a timely manner.
Certain information you provide on this form is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6),
respectively. For more information, see the last page of this application to read the Privacy Act Statement.
Mail your aPPliCa tion
The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative
contractor) that services your State is responsible for processing your enrollment application. To locate the
mailing address for your fee-for-service contractor, go to MedicareProviderSupEnroll.
CMS-855I (07/11)
2

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