Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 13

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SECTION 4: IMPORTANT ADDRESS INFORMATION
(Continued)
B. CORRESPONDENCE MAILING ADDRESS
This is the address where correspondence will be sent to you by the NSC MAC and/or the DME MAC, OR
Check here if you want all correspondence mailed to your Business Location Address in Section 2A and skip
this section.
If you are reporting a change to your Correspondence Mailing Address, check the box below and furnish the
effective date.
Change
Effective Date (mm/dd/yyyy):
Business Location Name
Attention (optional)
Correspondence Mailing Address Line 1 (P.O. Box or Street Name and Number)
Correspondence Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Telephone Number (if applicable)
Fax Number (if applicable)
E-mail Address (if applicable)
C. REVALIDATION REQUEST PACKAGE MAILING ADDRESS
This is the address where the NSC MAC will send your enrollment revalidation request package, OR
Check here if your revalidation request package should be mailed to your Business Location Address in Section
2A and skip this section, OR
Check here if your revalidation request package should be mailed to your Correspondence Mailing Address in
Section 4B and skip this section.
If you are reporting a change to your Revalidation Request Package Mailing Address, check the box below and
furnish the effective date.
Change
Effective Date (mm/dd/yyyy):
Business Location Name
Attention (optional)
Revalidation Request Package Mailing Address Line 1 (P.O. Box or Street Name and Number)
Revalidation Request Package Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Telephone Number (if applicable)
Fax Number (if applicable)
E-mail Address (if applicable)
CMS-855S (05/16)
12

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