Get Medicare 855i Enrollment Application Mapped Form

The Medicare 855i Enrollment Application is essential for physicians and non-physician practitioners seeking to enroll in the Medicare program. This guide provides clear, step-by-step instructions for completing the form online, ensuring that you provide all necessary information accurately.

Follow the steps to complete your Medicare 855i Enrollment Application online.

1. Press the ‘Get Form’ button to obtain the Medicare 855i Enrollment Application online.
2. Begin by reviewing Page 1 to ensure you are completing the appropriate application based on your provider type.
3. In Section 1, fill out the basic information, checking the appropriate box that corresponds to your reason for applying. Provide your Medicare Identification Number and National Provider Identifier (NPI) as required.
4. Complete Section 2, which includes identifying information. Ensure your name, date of birth, and social security number match your Social Security record. Fill out your correspondence address and indicate if you accept new Medicare patients.
5. If applicable, continue with Section 3 to report any final adverse legal actions or convictions as directed.
6. Move on to Section 4 to provide practice location information. Complete details for each location where services will be rendered, ensuring you indicate any changes, additions, or deletions accurately.
7. In Section 13, provide contact information for someone who can be reached regarding the application. This will ensure smooth communication between you and the Medicare contractor.
8. Finally, review the entire application for completeness and accuracy. Save your changes, download the form, and prepare to print it for submission.
9. Submit your application, along with any required supporting documents, to your designated Medicare fee-for-service contractor.

Complete your Medicare 855i Enrollment Application online today!