Loading
Get Form 855
How it works
-
Open form follow the instructions
-
Easily sign the form with your finger
-
Send filled & signed form or save
How to fill out the Form 855 online
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.
- Press the ‘Get Form’ button to access the Form 855, and open it in your preferred editor.
- Review the initial sections of the form, including your provider/supplier name and contact information. Ensure that the details match your existing records.
- In Section 1A, indicate that you are revalidating your Medicare enrollment by marking the appropriate box.
- Fill in all practice locations and ensure that you include every Provider Transaction Access Number (PTAN) that applies to your services.
- Enter your National Provider Identifier (NPI) accurately, as this will be essential for your enrollment process.
- Compile and attach any necessary documentation, such as certifications and Final Adverse Action documentation, ensuring you have everything required for substantiation.
- Complete the Certification page by signing and dating it, verifying all information is accurate.
- If applicable, include IRS documentation that confirms your legal business name.
- When you have filled out all sections and attached the necessary documents, review your submission one final time for any omissions or errors.
- 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.
The CMS 855B form is intended for institutional providers such as hospitals, clinics, and other healthcare facilities. This form is essential for organizations seeking to enroll in Medicare and access its benefits. By completing Form 855B, these providers can establish their eligibility and start serving Medicare beneficiaries.
Industry-leading security and compliance
US Legal Forms protects your data by complying with industry-specific security standards.
-
In businnes since 199725+ years providing professional legal documents.
-
Accredited businessGuarantees that a business meets BBB accreditation standards in the US and Canada.
-
Secured by BraintreeValidated Level 1 PCI DSS compliant payment gateway that accepts most major credit and debit card brands from across the globe.