CMS FORM 855I PDF

This tutorial has been created to assist you in completing the paper form CMS- I Physician and Non-Physician Practitioners Enrollment Application. You can also enroll in Medicare by filling out these forms electronically, online, using CMSI. Physicians and Non-Physician Practitioners. Physicians and . Education Department along with the Provider Enrollment. Department in an attempt to assist you with correctly completing the CMSI enrollment form the .

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Before you can enter the Noridian Medicare site, please read and accept an agreement to abide by the copyright rules regarding the information you find within this site. Last Updated Feb 01, User License Agreement and Consent to Monitoring.

CMS form 855I for new Medicare program enrollees

Section 2 – Identifying Information. If you have a second specialty, enter an S in the box next to your secondary specialty. Section 6 – Individuals Having Managing Control. Did you complete Section 2J questions on page 10, if you are a physical or occupational therapist in fodm practice?

Department of Defense procurements and the limited rights restrictions of FAR The ADA is a third-party beneficiary to this Agreement. It eliminates paperwork and saves time by reducing routine banking. Non-physician practitioners do not need to complete this section. Did 585i designate your primary specialty only one and your secondary specialties one cmz more on page 7, Section 2D Medical Specialtiesquestion 1. If there is more than one managing employee, copy and complete this section as needed.

Physicians and Non-Physician Practitioners.

Complete this application if you are a health care organization and you plan to bill Medicare for Part A medical services or would like to report a change to your existing Part A enrollment data. This address cannot be your billing agency address.

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CMS I Instructions – Noridian

You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. If you as 585i sole practitioner or your organization sees patients in more than one location, complete this section for each location.

The SSN must be in this section. If the answer is YES, complete question 2 and attach documentation and information about the resolution for each adverse legal action. The address cannot be a billing agency’s address. State Street, Chicago, IL If this section applies to you, be sure the legal business name is listed as it appears with the IRS.

Did you read Section 17 on page 27 to ensure that you have submitted correct and complete supporting documentation? If ofrm are multiple contacts for this application, copy this section cs complete it for each contact.

This is a list of supporting documents which are often missed. If you checked Diagnostic Radiology as your specialty, and you will be billing Medicare for the technical component vorm the diagnostic tests, did foem also complete a CMSB enrollment form as an independent diagnostic testing facility IDTF? If you choose not to accept the agreement, you will return to the Noridian Medicare home page.

If the provider is submitting a change of information application and is currently receiving electronic payments, the is not required.

If the individual does not want to be in a participating status with Medicare, they should submit a letter stating they wish to be Nonparticipating. Participation Agreements on initial enrollments. This must be the address such as a home address where the carrier can contact the provider directly. An individual who has formed a professional corporation, professional association, limited liability company, etc.

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Step-by-step directions to completing CMSI application

Used as a first contact for all for additional information cmw. Section 1 – Basic Information. If yes, did you attach a copy of the final adverse action documentation and its resolution? No fee schedules, basic unit, relative values or related listings are included in CPT. Some supporting documentation requirements may change due to the laws in your state.

The use of blue ink is preferred. Applicants will mark this box if they were previously enrolled in Medicare, but their number s was were deactivated. Electronic Funds Transfer Agreement This form is used to have your Medicare payments deposited directly into your bank account. Currently enrolled as an MDPP supplier with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction e.

Section 8 – Billing Agency Information.

Please indicate your personal NPI number in section 1. Did you include the name s of all managing employees? The following chart describes when and how First Coast will contact providers based on the contact information provided in your enrollment application.

Did you complete Section 2I questions on page 10, if you are a psychologist billing independently. Did you fill in your personal information on page 5 in Section 2A, Identifying Informationrelative to yourself as well as to your license and certification corm If applicable, did you designate your non-physician specialty on page 8, Section 2D, question 2.