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Get CMS-855R 2016

Get the current version of the CMS-855R, go to http://www.cms.gov/MedicareProviderSupEnroll. INSTRUCTIONS FOR COMPLETING THIS APPLICATION • • • • Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred. Sign and date the certification statement(s) as appropriate. Enter all NPIs in the applicable sections. Keep a copy of your completed Medicare reassignment package for your own records. ADDITIONAL INFORMATION When establishing a new reassignment.

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