SECTION 1: BASIC INFORMATION
(Continued)
C. REASON FOR SUBMITTING THIS APPLICATION
Check one box and complete the sections as indicated.
Complete all sections
You are a new enrollee in Medicare or are enrolling a
new business location with a tax identification number not
previously enrolled with the NSC MAC.
You are adding a new business location using a tax
Complete sections 1–7, 9 (for managing
employee only), 11 (optional), 12, and either
identification number currently enrolled with the NSC MAC.
14 or 15
You are reactivating your Medicare supplier billing number. Complete all sections
Complete all sections
You are revalidating your Medicare enrollment.
Complete sections 1, 2a, 4b, 4D, 11 (optional),
You are voluntarily terminating your Medicare enrollment.
and either 14 or 15
Effective date of termination:
Go to Section 1D
You are changing your Medicare enrollment information
other than your tax identification number.
Complete all sections
You are changing your Tax Identification Number.
D. WHAT INFORMATION IS CHANGING?
Check all that apply and complete the required sections.
PLEASE NOTE: When reporting ANY information, sections 1B, 7 and either 14 or 15 MUST always be
Completed in addition to completing the information that is changing within the required section.
CHECK ALL THAT APPLY
REQUIRED SECTIONS
1, 2, 7, 11 (optional), 12 (if applicable), and
Current Business Location
either 14 or 15
1, 3, 7, 11 (optional), 12 (if applicable), and
Supplier Type (submit licensure if applicable)
either 14 or 15
Products and Services (submit accreditation if applicable)
Accreditation Information
1, 3, 7, 11 (optional), 12 (if applicable), and
either 14 or 15
1, 4 as applicable for the address that
Address Information
is being changed, 7, 11 (optional), 12 (if
1099 Mailing Address
applicable), and either 14 or 15.
Correspondence Mailing Address
Revalidation Mailing Address
Remittance/Special Payment Mailing Address
Record Storage Address
1, 5, 7, 11 (optional), 12, and either 14 or 15
Comprehensive Liability Insurance Information
1, 6, 7, 11 (optional), 12, and either 14 or 15
Surety Bond Information
1, 7, 11 (optional), 12, and either 14 or 15
Final Adverse Legal Actions
1, 7, 8 and/or 9, 11 (optional), 12 (if
Ownership and/or Managing Control Information
(Organizations and/or Individuals)
applicable), and either 14 or 15
1, 7, 10, 11 (optional), and either 14 or 15
Billing Agency Information
1, 7, 9, 11 (optional), 12, 14 and 15
Delegated Official
1, 7, 9, 11 (optional), 12 (if applicable), 15
Authorized Official
1, 7, 11 (optional), 12 (if applicable), and
Any other information not specified above
either 14 or 15 and the applicable section or
sub-section that is changing.
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
