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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An additional CMSI must be completed for each non-physician specialty type. All physicians, as well as all non-physician practitioners listed below must complete this application in order to initiate the enrollment process:. There are times in which the various content contributor primary resources are not synchronized cjs updated on the same time interval.

The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. The information obtained from this website application, Noridian Medicare Portal, is as current as possible. Help us make your experience better. Practice Location Information Section 4A: If you as a sole practitioner or your organization sees patients in more than one location, complete this section for each location.

An individual who has formed a professional corporation, professional association, limited liability company, etc. Be sure to enter a P for Primary in the box next to your specialty.

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CMS form 855I for new Medicare program enrollees

Mail completed forms, including a handwritten signature and all supporting documentation, to Novitas Solutions at one of the address listed below. Don’t want to use paper, print and mail? Last Updated Feb 01, Please click here to see all U. This system is provided for Government authorized for, only.

Used for additional information requests if the contact information on the application is incomplete. Section 2 – Identifying Information. The AMA does not directly or indirectly practice medicine or dispense medical services.

State Street, Chicago, IL Government and other information systems, information accessed through the computer system is confidential and for authorized users only. An individual practitioner who will provide services cmss a private setting. User License Agreement and Consent to Monitoring.

Additionally, ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. Certification Statement The applicant must sign and date this section.

The signature must be an original signature and cannot be a photocopy or stamp. Consent to Monitoring Warning: Did you read Section 17 on page 27 to ensure that you have submitted correct and complete supporting documentation? Electronic Funds Transfer Agreement.

Step-by-step directions to completing CMSI application

Foem managing employee means a general manager, business manager, administrator, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of the supplies, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee or the supplier.

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If the individual c,s not want to be in a participating status with Medicare, they should submit a letter stating they wish to be Nonparticipating. If you choose not to accept the agreement, you will return to the Noridian Medicare home page.

Reassignment of Medicare Benefits Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. Indicate the effective date of termination, the provider number, and the NPI.

A medical practice or clinic that will bill for Medicare Part B services e.

End users do not act for or on behalf of the CMS. Enrolled with a Medicare contractor but have 85i5 a practice location in a geographic territory services by Novitas Solutions. Each new idea, self-service tool, or new article depends on you and your participation in our ForeSee customer satisfaction survey.

If you do not use a billing agency, you can continue with Section 13 on page