Get Department Of Health And Human Services Centers For Medicare &amp - Cms

This guide is designed to assist users in filling out the DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services form efficiently and accurately. Whether you are a physician or a non-physician practitioner, this step-by-step process will help you navigate the online enrollment for Medicare.

Follow the steps to successfully complete the form

1. Click the ‘Get Form’ button to access the enrollment application and open it in the editor.
2. Complete Section 1 (Basic Information) by selecting 'new enrollee' as your status.
3. In Section 2 (Identifying Information), fill out details in subsections 2A, 2B, 2D, and if applicable, 2H and 2K.
4. Review Section 3 (Final Adverse Actions/Convictions) and provide any necessary disclosures that pertain to your professional history.
5. Complete Section 13 (Contact Person) with reliable contact information.
6. Sign and date Section 15 (Certification Statement), using blue ink to ensure clarity.
7. Prepare a cover letter stating that you are enrolling solely for ordering and referring items or services for Medicare beneficiaries.
8. Mail your completed form along with the cover letter to your designated Medicare enrollment contractor, which you can identify using the relevant resource.
9. Wait for confirmation from your Medicare enrollment contractor, who will verify your information and notify you once your enrollment is processed.
10. Review the letter once received to ensure your details are correct and that you are listed in the Ordering Referring File.

Take the next step and complete your enrollment documents online today.