Get Cms 855 Cms 20134

Filling out the Cms 855 Cms 20134 is an essential step for organizations wishing to enroll in the Medicare Diabetes Prevention Program. This guide provides a clear and supportive approach to completing the form online, ensuring that users with varying levels of experience can navigate the process with ease.

Follow the steps to successfully complete the application.

1. Click the 'Get Form' button to access the Cms 855 Cms 20134 application form and open it in your preferred online editing platform.
2. Begin with Section 1: Basic Information, where you'll select the reason for submitting the application (e.g., new enrollment, reactivation, etc.). Complete all applicable fields carefully.
3. Move to Section 2: Identifying Information. Here, provide details such as the legal business name, tax identification number, and type of supplier. Ensure all names and information match those on file with the IRS.
4. Complete Section 3: Final Adverse Legal Actions/Convictions, where you must declare any adverse legal actions that may affect eligibility.
5. In Section 4, fill out your MDPP location information, indicating where services will be provided and if there are any community settings involved.
6. Proceed to Sections 5 and 6 to disclose ownership interests or managing control information, ensuring to list all individuals and organizations that meet the ownership criteria.
7. Use Section 7 for the coach roster, where you will detail the eligibility of MDPP coaches and ensure compliance with standards.
8. If applicable, complete Section 8 to provide information about any billing agencies you may use for claims submission.
9. Fill out Section 13: Contact Person, including the contact information of someone who can be reached if there are questions about the application.
10. Once all sections are filled, review the Certification Statement in Section 15 carefully before signing. Ensure all required documentation is attached.
11. Finally, submit the completed form and all required documents to the appropriate Medicare contractor, and retain a copy for your records.

Complete your application form online today to ensure timely Medicare enrollment.