Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 6
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27SECTION 1: BASIC INFORMATION
This section captures basic information and information about the reason you are submitting this application.
A. BUSINESS LOCATION
Provide the two-letter State Code (e.g., TX for Texas) where this business is physically located.
B. BUSINESS IDENTIFICATION
DMEPOS suppliers must furnish their Legal Business Name (LBN) as reported to the Internal Revenue Service
(IRS), National Provider Identifier (NPI), Tax Identification Number (TIN), and supplier billing number (if issued)
below.
NOTE: Each business location MUST have its own NPI, unless enrolling as a sole proprietor/proprietorship with
multiple locations. See Section 2C.
Legal Business Name (LBN)
National Provider Identifier (NPI)
Tax Identification Number (TIN)
Supplier Billing Number (if issued)
Read this in full prior to indicating the reason for submission in Section 1C.
NEW ENROLLEES AND THOSE REPORTING A NEW TAX ID NUMBER
You are considered a new enrollee if you are:
• Enrolling in the Medicare program as a DMEPOS supplier for the first time under the tax identification
number reported in Section 1B.
• Currently enrolled in the Medicare program as a DMEPOS supplier but have a new tax identification
number. If you are reporting a change to your tax identification number, you must complete a new
CMS-855S enrollment application in its entirety.
• A currently enrolled DMEPOS supplier under new ownership with a different tax identification number.
(NOTE: New owners of existing DMEPOS suppliers must submit a dated bill of sale with the effective date of
the new ownership.)
CURRENTLY ENROLLED MEDICARE DMEPOS SUPPLIERS
Adding a new location
If you are currently enrolled as a Medicare DMEPOS supplier and are applying to enroll a new business
location using a tax identification number that is already enrolled with the NSC MAC, you will need to
complete only the required sections listed in Section 1C of this application for the new location.
Change of information other than adding a new location
If you are adding, removing, or changing information under your current Medicare supplier billing number,
including a change of ownership that does not change the current tax identification number, you will need
to complete the appropriate sections as instructed and submit any new documentation. Any change to your
existing enrollment data must be reported within 30 days of the effective date of the change.
Reactivation
If your Medicare DMEPOS supplier billing number was deactivated, you will be required to submit an updated
CMS-855S. You must also meet all current requirements for your supplier type to reactivate your supplier
billing number.
Revalidation
If you have been contacted by the NSC MAC to revalidate your Medicare enrollment, you will be required to
submit an updated enrollment application. Do not submit an application for revalidation until you have been
contacted by the NSC MAC.
Voluntary termination
If you will no longer provide DMEPOS items or services to Medicare beneficiaries, you should voluntarily
terminate your enrollment in the Medicare program as a DMEPOS supplier.
NOTE: Enrollment applications submitted for “NEW ENROLLEES” MUST be signed by an Authorized Official.
CMS-855S (05/16)
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Parent category: Medical