SECTION 4: IMPORTANT ADDRESS INFORMATION
(Continued)
D. REMITTANCE NOTICES/SPECIAL PAYMENTS MAILING ADDRESS
Medicare will issue all routine payments via electronic funds transfer (EFT). Since payment will be made
by EFT, the special payments address below should indicate where all other payment information (e.g.,
remittance notices, non-routine special payments) should be sent, OR
Check here if your Remittance Notices/Special Payments should be mailed to your Business Location Address in
Section 2A and skip this section, OR
Check here if your Remittance Notices/Special Payments should be mailed to your Correspondence Mailing
Address in Section 4B and skip this section.
NOTE: If you are a new enrollee, you must submit an EFT Authorization Agreement (CMS-588) with this
application.
If you need to make changes to your current EFT Authorization Agreement (CMS-588), contact your DME MAC.
If you are reporting a change to your Remittance Notice/Special Payment Mailing Address, check the box
below and furnish the effective date.
Change
Effective Date (mm/dd/yyyy):
NOTE: Payments will be made in the supplier’s legal business name as shown in Section 1B.
Special Payments Address Line 1 (PO Box or Street Name and Number)
Special Payments Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
E. MEDICARE BENEFICIARY MEDICAL RECORDS STORAGE ADDRESS
If the Medicare beneficiaries’ medical records are stored at a location other than the Business Location Address
in Section 2A in accordance with 42 C.F.R. section 424.57 (c)(7)(E), complete this section with the name and
address of the storage location. This includes the records for both current and former Medicare beneficiaries.
Post office boxes and drop boxes are not acceptable as a physical address where Medicare beneficiaries’
records are maintained. The records must be the supplier’s records, not the records of another supplier. If all
records are stored at the Business Location Address reported in Section 2A, check the box below and skip this
section.
Records are stored at the Business Location Address reported in Section 2A.
If you are adding or removing a storage location, check the box below and furnish the effective date.
Add
Remove
Effective Date (mm/dd/yyyy):
1. Paper Storage
Name of Storage Facility
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
2. Electronic Storage
Do you store your patient medical records electronically?
Yes
No
If yes, identify where/how these records are stored below. This can be a website, URL, in-house software
program, online service, vendor, etc. This must be a site that can be accessed by the NSC MAC if necessary.
Name of Storage Facility
CMS-855S (05/16)
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Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers
Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners
Medical
