Form Cms-855i - Medicare Enrollment Application - Physicians And Non-Physician Practitioners Page 9

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SECtion 2: idEntifying inforMation
(Continued)
d. 2. non–Physician Specialty
If you are a non-physician practitioner, check the appropriate box to indicate your specialty.
All non-physician practitioners must meet specific licensing, educational, and work experience
requirements. If you need information concerning the specific requirements for your specialty, contact the
Medicare fee-for-service contractor.
If you want to enroll as more than one non-physician specialty type,
Check only one of the following:
you must submit a separate CMS-855I application for each.
Anesthesiology assistant
Audiologist
Certified nurse midwife
Certified registered nurse anesthetist
Clinical nurse specialist
Clinical social worker
Mass immunization roster biller
Nurse practitioner
Occupational therapist in private practice
Physical therapist in private practice
Physician assistant
Psychologist, clinical
Psychologist billing independently
Registered dietitian or nutrition professional
Speech Language Pathologist
Undefined non-physician practitioner type
:
(Specify)
_______________________________________
_______________________________________
_______________________________________
CMS-855I (07/11)
8

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