Medicare Enrollment Application
form for all Physicians and Non-Physician Practitioners
You are encouraged to begin using this
form immediately (May 1, 2006).
MLN Matters Information Document on Enrollment Application
Form 855.
CMS
Medicare Enrollment Application Form 855I (click
here to download form)
All
physicians, as well as all non-physician practitioners
listed below, must complete this application to
initiate the enrollment process:
| Anesthesiology Assistant |
Occupational therapist
in private practice |
| Audiologist |
Physical therapist in
private practice |
| Certified nurse midwife |
Physician assistant |
| Certified registered
nurse anesthetist |
Psychologist, Clinical |
| Clinical nurse specialist |
| Clinical social worker |
Psychologist billing independently |
| Mass immunization
roster biller |
Registered Dietitian or Nutrition
Professional |
| Nurse practitioner |
|
If
your supplier type is not listed above, contact the
fee-for-service contractor before you submit
this application.
Complete this application if you are an individual
practitioner who plans to bill Medicare and you are:
• An individual practitioner who will provide
services in a private setting.
• An individual practitioner who will provide
services in a group setting. If you plan to render
all of
your services in a group setting, you will complete
Sections 1-4 and skip to Sections 14 through 17
of this application.
• Currently enrolled with a Medicare fee-for-service
contractor but need to enroll in another fee-forservice
contractor’s jurisdiction (e.g., you have opened
a practice location in a geographic territory
serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to
make changes to your enrollment information (e.g.,
you
have added or changed a practice location).
• An individual who has formed a professional
corporation, professional association, limited liability
company, etc., of which you are the sole owner.
If you provide services in a group/organization setting,
you will also need to complete a separate
application, the CMS-855R, to reassign your benefits
to each organization. If you terminate your
association with an organization, use the CMS-855R
to submit that change.
If you perform diagnostic testing, you may be required
to enroll as an Independent Diagnostic Testing
Facility (IDTF) if substantial portions of your diagnostic
tests (other than clinical laboratory or pathology)
are provided to patients who are not your patients.
Check with your Medicare fee-for-service contractor
to
determine whether or not you need to enroll as an
IDTF. If you only furnish diagnostic tests, claims
must
be submitted as an IDTF and you must complete and
submit the CMS-855B.
