SEE SECTION 17 TO FIND A LIST OF THE SUPPORTING DOCUMENTATION THAT MUST BE SUBMITTED WITH THIS APPLICATION. DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0685 Expires: 09/26 WHO SHOULD SUBMIT THIS APPLICATION Institutional providers must complete this application to enroll in the Medicare program and receive a Medicare billing number. Institutional providers can apply for enrollment in the Medicare program or make a change in thei.
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How to fill out the Form CMS-855A Medicare Enrollment Application online
The Form CMS-855A Medicare Enrollment Application is essential for institutional providers to enroll in the Medicare program and obtain a Medicare billing number. This guide provides a step-by-step approach to filling out the form online effectively.
Follow the steps to complete the CMS-855A form online:
- Press the ‘Get Form’ button to obtain the form and open it in the editor.
- Carefully read the instructions to determine if this is the correct application for your situation.
- Complete Section 1, providing your basic information including the reason for submitting the application.
- Complete Section 2 with identifying information, including your legal business name and National Provider Identifier (NPI).
- Fill out Section 3 regarding any final adverse legal actions, ensuring to provide complete and accurate details.
- Provide details about your practice locations in Section 4, listing all facilities where services will be rendered.
- In Section 5, report ownership interest and managing control if applicable, detailing any organizations with ownership stakes.
- Complete Section 6 for individuals with ownership interest or managing control, ensuring to include all relevant individuals.
- If using a billing agency, fill out Section 8 with the billing agency information. Otherwise, you may skip this section.
- Verify all entries are complete, accurate and that required supporting documentation is attached.
- Finally, save changes, download, print, or share the completed form as needed.
Start completing your Form CMS-855A online to ensure your Medicare enrollment process is smooth and efficient.
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