Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 5

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SECtion 1: baSiC inforMation
(Continued)
b. Check all that apply and complete the required sections.
rEQuirEd SECtionS
1, 2 (complete only those sections that are
Identifying Information
changing), 3, 13 and 15
1, 2A, 3, 13 and 15
Final Adverse Actions/Convictions
Practice Location Information, Payment Address
1, 2A, 3, 4 (complete only those sections that are
changing), 13 and 15
and Medical Record Storage Information
1, 2A, 3, 6, 13, and 15
Individuals Having Managing Control
1, 2A, 3, 8 (complete only those sections that are
Billing Agency Information
changing), 13 and 15
CMS-855I (07/11)
4

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