CMS-855ISEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION.SEE PAGE 3 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION.SEE SECTION 12 FOR A LIST OF SUPPORTING DOCUMENTATION TO BE SUBMITTED WITH THIS APPLICATION.TO VIEW YOUR CURRENT MEDICARE ENROLLMENT RECORD GO TO: HTTPS://PECOS.CMS.HHS.GOVMEDICARE ENROLLMENT APPLICATIONPHYSICIANS ANDNON-PHYSICIAN PRACTITIONERS American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICESForm ApprovedOMB No. 0938-1355Expires: 12/21 WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATIONAll physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either:225 The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or225 The paper CMS-855I enrollment application. Be sure you are using the most current version.For additional information regarding the Medicare enrollment process, including Internet-based PECOS and to get the current version of the CMS-855I, go to http://www.cms.gov/MedicareProviderSupEnroll.Complete this application if you are an individual practitioner or eligible professional who plans to bill Medicare and you are:225 Currently enrolled in Medicare to order and certify and want to enroll as an individual practitioner to submit claims for services rendered.225 An individual practitioner or eligible professional who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner.225 Currently enrolled in Medicare and you received notice to revalidate your enrollment.225 Previously enrolled in Medicare and you need to reactivate your Medicare billing number to resume billing.225 Currently enrolled in Medicare and need to enroll in another Medicare Administrative Contractor222s (MAC222s) jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another MAC).225 Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location). 225 Voluntarily terminating your Medicare enrollment.If you provide services in an entity setting, you will also need to complete a CMS-855R (Reassignment of Medicare Benefits), for each entity that you reassign your benefits. If you terminate your association with an entity, use the CMS-855R to report that termination.NOTE: For the purposes of this section of this application, an entity is defined as an individual, private practice, group/clinic, or any organization to which you will reassign your Medicare benefits.BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATIONThe Provider Transaction Access Number (PTAN), often referred to as a Medicare Supplier Number or Medicare Billing Number is a generic term for any number other than the National Provider Identifier (NPI) that is used by a practitioner to bill the Medicare program. The NPI is the standard unique health identifier for health care providers and suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). To enroll in Medicare, you must obtain an NPI and furnish it on this application prior to enrolling in Medicare or when submitting a change to your existing Medicare enrollment information. Applying for the NPI is a process separate from Medicare enrollment. To obtain an NPI, you may apply online at https://nppes.cms.hhs.gov. For more information about NPI enumeration, visit www.cms.gov/NationalProvIdentStand.NOTE: The Name and Social Security Number (SSN) that you furnish in section 2A and if applicable Legal Business Name (LBN) and Tax Identification Number (TIN) you furnish in section 4A must be the same Name, SSN, LBN and TIN you used to obtain your NPI. Once this information is entered into PECOS from this application, your Name, SSN, LBN, TIN and NPI must match exactly in both the Medicare Provider Enrollment Chain and Ownership System and the National Plan and Provider Enumeration System.CMS-855I (12/18) 1 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR COMPLETING THIS APPLICATION All information on this form is required with the exception of those 037elds speci037cally marked as 223optional.224 Any 037eld marked as optional is not required to be completed nor does it need to be updated or reported as a 223change of information224 as required in 42 C.F.R. section 424.516. However, it is highly recommended that if reported, these 037elds be kept up-to-date.225 Type or print all information so that it is legible. Do not use pencil. 225 When necessary to report additional information, copy and complete the applicable section as needed.225 Attach all required supporting documentation. 225 Keep a copy of your completed Medicare enrollment package for your own records.IMPORTANT INFORMATION ABOUT INDIVIDUAL VERSUS ORGANIZATION NPIs Individual Health Care Providers, including Sole Proprietors (Entity Type 1): Individual health care providers are eligible for an Entity Type 1 NPI (Individuals). A sole proprietor/sole proprietorship is an individual, and as such, is eligible for an individual Type 1 NPI. The sole proprietor must apply for a Type 1 NPI using his or her own Social Security Number (SSN), not an Employer Identification Number (EIN) even if he/she has an EIN. A sole proprietor does not include a single member LLC regardless of how they elect to be taxed.Organizational Health Care Providers (Entity Type 2): Organizational health care providers are eligible for an Entity Type 2 NPI (Organizations). Organizational health care providers may have a single employee or thousands of employees. Examples of organizational providers include hospitals, home health agencies, groups/clinics, nursing homes, ambulance companies, health care provider corporations formed by groups/individuals, and single member LLCs with an EIN, not individual health care providers.TIPS TO AVOID DELAYS IN YOUR ENROLLMENT225 Complete all required sections, as shown in section 1.225 Enter your NPI(s) in the applicable section(s).225 Include the Electronic Funds Transfer (EFT) Authorization Agreement (when applicable) with your enrollment application.225 Sign and date section 15. 225 Respond timely to development/information requests.ADDITIONAL INFORMATION225 You may visit our website to learn more about the enrollment process via the Internet-Based Provider Enrollment Chain and Ownership System (PECOS) at: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/InternetbasedPECOS.html. Also, all of the CMS-855 applications are all located on the CMS webpage: https://www.cms.gov/medicare/cms-forms/cms-forms/cms-forms-list.html. Simply enter 223855224 in the 223Filter On:224 box on this page and only the application forms will be displayed to choose from.225 The MAC may request additional documentation to support and validate information reported on this application. You are responsible for providing this documentation within 30 days of the request per 42 C.F.R. section 424.525(a)(1) and (2).225 The information you provide on this form is protected under 5 U.S.C. section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application to read the Privacy Act Statement.CMS-855I (12/18) 2 American LegalNet, Inc. www.FormsWorkFlow.com ACRONYMS COMMONLY USED IN THIS APPLICATIONC.F.R: Code of Federal RegulationsEFT: Electronic Funds TransferEIN: Employer Identification NumberIHS: Indian Health ServiceIRS: Internal Revenue ServiceLBN: Legal Business NameLLC: Limited Liability CorporationMAC: Medicare Administrative ContractorNPI: National Provider IdentifierNPPES: National Plan and Provider Enumeration SystemPTAN: Provider Transaction Access Number also referred to as the Medicare Identification NumberSSN: Social Security NumberTIN: Tax Identificatio