Get Form 855

Filling out the Form 855 is a critical step for providers seeking to revalidate their Medicare enrollment. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to complete the Form 855 online.

1. Press the ‘Get Form’ button to access the Form 855, and open it in your preferred editor.
2. Review the initial sections of the form, including your provider/supplier name and contact information. Ensure that the details match your existing records.
3. In Section 1A, indicate that you are revalidating your Medicare enrollment by marking the appropriate box.
4. Fill in all practice locations and ensure that you include every Provider Transaction Access Number (PTAN) that applies to your services.
5. Enter your National Provider Identifier (NPI) accurately, as this will be essential for your enrollment process.
6. Compile and attach any necessary documentation, such as certifications and Final Adverse Action documentation, ensuring you have everything required for substantiation.
7. Complete the Certification page by signing and dating it, verifying all information is accurate.
8. If applicable, include IRS documentation that confirms your legal business name.
9. When you have filled out all sections and attached the necessary documents, review your submission one final time for any omissions or errors.
10. Save your changes, download the form, and print it. Depending on your preference, you can either mail your completed application or submit it through the Internet-based PECOS, as per your selected method.

Start filling out the Form 855 online to ensure your Medicare enrollment continues without interruption.