What is a CMS 855 form?

Paper Enrollment Applications The following forms can be used for initial enrollment, revalidations, changes in status, and voluntary termination: CMS-855A for Institutional Providers. CMS-855B for Clinics, Group Practices, and Certain Other Suppliers. CMS-855I for Physicians and Non-Physician Practitioners.

What is the difference between 855I and 855R?

CMS-855I: For reassigning individuals who are new to the Medicare program, or not PECOS enrolled (sections 1, 2, 3, 4B, 13, and 15). CMS-855I: For employed physician assistants (sections 1, 2, 3, 13, and 15). CMS-855R: Individuals reassigning (entire application).

What is enrollment type 855I?

Medicare Enrollment Application - Physicians and Non-Physician Practitioners.

What is an 855I form?

Form # CMS 855I. Form Title. Medicare Enrollment Application - Physicians and Non-Physician Practitioners.

Who is the CMS Form 855 I the enrollment application for?

All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.

Get Mmr User Enrollment Form

Change, Delete) per form. 2. Provide all of the requested information. 3. The physician and each designated staff must sign the application. NEW (Add participants) CHANGE (Indicate information to be changed.) DELETE (Suspend all participant rights) Effective Date First Notification E-mail Address (required): Second Notification E-mail Address (optional): (Type or Print) (First) (Middle) (Last) Physician, ME: License Number: Request Participant ID: E-mail Address: Ph.

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