CMS-855A 2011 free printable template

MEDICARE ENROLLMENT APPLICATION INSTITUTIONAL PROVIDERS CMS-855A SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION SEE PAGE 3 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION.

How to fill out CMS-855A

How to fill out CMS-855A

1. Obtain the CMS-855A form from the Medicare website or through your regional Medicare Administrative Contractor (MAC).
2. Fill out the provider information section, including your name, National Provider Identifier (NPI), and other identifying details.
3. Provide details about your practice location, including the address, phone number, and any applicable Tax Identification Numbers (TINs).
4. Specify the type of provider you are, such as individual practitioner or group practice.
5. Complete the sections related to ownership and managing control, if applicable.
6. Include information about any prior Medicare billing history or changes to your practice.
7. Review the certification and signature section, ensuring all information is accurate.
8. Submit the completed form to your designated MAC either via mail or through the electronic submission portal.

Who needs CMS-855A?

1. The CMS-855A is needed by individual healthcare providers and organizations that wish to enroll in Medicare as a provider or supplier.
2. It is specifically required for physicians, non-physician practitioners, and entities such as group practices that bill Medicare for services.

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What is CMS-855A?

CMS-855A is a form used by Medicare to enroll provider organizations, such as hospitals or group practices, in the Medicare program.

Who is required to file CMS-855A?

Any organization or entity that wishes to enroll in Medicare and receive reimbursement for services provided to Medicare beneficiaries must file CMS-855A.

How to fill out CMS-855A?

CMS-855A can be filled out online through the CMS website or by downloading a paper form. Detailed instructions are provided with the form to guide through entering required information accurately.

What is the purpose of CMS-855A?

The purpose of CMS-855A is to collect necessary information to determine the Medicare enrollment status of provider organizations and to facilitate proper billing and reimbursement.

What information must be reported on CMS-855A?

Information that must be reported on CMS-855A includes the organization's legal name, address, ownership details, provider type, and any prior Medicare enrollment or disqualification history.