Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 10

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SECTION 3: PRODUCTS/ACCREDITATION INFORMATION
A. TYPE OF SUPPLIER
The supplier must meet all Medicare requirements for the DMEPOS supplier type checked. Any specialty
personnel including, but not limited to, respiratory therapists, and orthotics/prosthetics personnel, must meet
all licensure requirements applicable to its supplier type and applicable to the products and services checked
in sections 3C and 3D.
Check all that apply:
Ambulatory Surgical Center
Nursing Facility (other)
Department Store
Occularist
Grocery Store
Occupational Therapist
Home Health Agency
Optician
Hospital
Orthotics Personnel
Indian Health Service or Tribal Facility
Oxygen and/or Oxygen Related Equipment Supplier
Intermediate Care Nursing Facility
Pedorthic Personnel
Medical Supply Company
Pharmacy
Medical Supply Company
Physical Therapist
with Orthotics Personnel
Physician
Medical Supply Company
Physician/Dentist
with Pedorthic Personnel
Physician/Optometrist
Medical Supply Company
Prosthetics Personnel
with Prosthetics Personnel
Prosthetic and Orthotic Personnel
Medical Supply Company
Rehabilitation Agency
with Prosthetic and Orthotic Personnel
Skilled Nursing Facility
Medical Supply Company
Sleep Laboratory/Medicine
with Registered Pharmacist
Sports Medicine
Medical Supply Company
Other
with Respiratory Therapist
B. ACCREDITATION INFORMATION
NOTE: If more than one accreditation needs to be reported, copy and complete this section for each.
Check one of the following and furnish any additional information as requested:
The enrolling supplier business location in Section 2A is accredited.
The enrolling supplier business location in Section 2A is exempt from accreditation requirements.
To determine if you qualify for exemption, go to
Name of Accrediting Organization
Effective Date of Current Accreditation (mm/dd/yyyy)
Expiration Date of Current Accreditation (mm/dd/yyyy)
C. NON-ACCREDITED PRODUCTS
Check all that apply. These products do not require accreditation.
Epoetin
Immunosuppressive Drugs
Infusion Drugs
Nebulizer Drugs
Oral Anticancer Drugs
Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)
NOTE:
Check here if the supplier provides one or more of the products shown above but does not furnish
any of the products and/or services listed in Section 3D. If checked, skip Section 3D and continue to
Section 4.
CMS-855S (05/16)
9

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