Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 6

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SECtion 2: idEntifying inforMation
a. Personal information:
your name, date of birth, and social security number must coincide with the
information on your social security record.
First Name
Middle Initial
Last Name
Jr., Sr., M.D., D.O., etc.
Other Name, First
Middle Initial
Last Name
Jr., Sr., M.D., D.O., etc.
Type of Other Name
Former or Maiden Name
Professional Name
Other (Describe):____________________________________
Date of Birth (mm/dd/yyyy)
State of Birth
Country of Birth
Gender
Social Security Number
Male
Female
Medical or other Professional School (Training
Year of Graduation (yyyy)
DEA Number (if applicable)
Institution, if non-MD)
license information
License Not Applicable
License Number
State Where Issued
Effective Date (mm/dd/yyyy)
Expiration/Renewal Date (mm/dd/yyyy)
Certification information
Certification Not Applicable
Certification Number
State Where Issued
Effective Date (mm/dd/yyyy)
Expiration/Renewal Date (mm/dd/yyyy)
new Patient Status information
Do you accept new Medicare patients?
Yes
No
b. Correspondence address
Provide contact information for the person shown in Section 2A above. Once enrolled, the information
provided below will be used by the fee-for-service contractor if it needs to contact you directly. This
address cannot be a billing agency’s address.
Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Suite, Room, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
CMS-855I (07/11)
5

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