Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (Dmepos) Suppliers Page 8

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SECTION 2: IDENTIFYING INFORMATION
A. BUSINESS LOCATION INFORMATION
• DMEPOS suppliers must complete and submit a separate CMS-855S enrollment application to enroll each
physical location (i.e., store or other retail establishment) used to furnish Medicare covered DMEPOS to
Medicare beneficiaries, except for locations only used as warehouses or repair facilities.
• The address must be a specific street address as recorded by the United States Postal Service. Do not furnish
a P.O. Box. If you are located in a hospital and/or other health care facility and you provide services to
patients at that facility, furnish the name and address of the hospital or facility.
• A change to the business location address requires submission of professional and business licenses for the
new address, and proof of insurance covering the new address.
If you are reporting a change of information to your current business location, check the box below and
furnish the effective date.
Change
Effective Date (mm/dd/yyyy):
Business Location Name/Doing Business As Name
Business Location Address Line 1 (Street Name and Number)
Business Location Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code + 4
Telephone Number
Fax Number (if applicable)
E-mail Address (if applicable)
Date this Business Started at this Location (mm/dd/yyyy) Date this Business Terminated at this Location (if applicable) (mm/dd/yyyy)
B. HOURS OF OPERATION
List your posted hours of operation as displayed at the business location in Section 2A above.
If you are reporting a change to your hours of operation, check the box below and furnish the effective date.
Change
Effective Date (mm/dd/yyyy):
You must list all hours of each day you are open to the public.
Check and/or complete all boxes and/or sections for each day as appropriate.
Open 24/7 (Open 24 hours a day, 7 days a week)
By Appointment Only (no fixed days or hours)
NOTE: “By Appointment Only” can only be checked if you meet the exemption requirements stated in
42 C.F.R. section 424.57(c)(30).
Hours (indicate A.M. or P.M.)
Hours (indicate A.M. or P.M.)
Total Hours Open to
Day of Week
the Public Each Day
Open
Close
Open
Close
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Total Hours Open to the Public Weekly
0
CMS-855S (05/16)
7

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