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John G. Ranges, Sr. Building 855 N. Wolfe St. Access Request Form×Required to be filled in. *First Name MI×Last Name×Primary Phone NumberSecondary Phone NumberEmail Address×Employee ID NumberOther

How to fill out 855 n

How to fill out 855 n

1. Step 1: Begin by downloading the CMS 855N form from the official Centers for Medicare & Medicaid Services (CMS) website.
2. Step 2: Fill out the first section, which includes providing your individual or organizational information such as your name, address, Social Security number or employer identification number, and contact details.
3. Step 3: Complete the second section, where you'll provide the details of your existing supplier billing privileges, including the Medicare/Medicaid Identification number, effective date, and termination date if applicable.
4. Step 4: Fill out the third section if you are adding a new practice location. This section requires information about the location address, contact person, telephone number, and primary specialty.
5. Step 5: Complete the fourth section if you are adding a new physician or non-physician practitioner to your group practice. Provide the necessary details such as the individual's name, Social Security number, specialty, and contact details.
6. Step 6: Fill out the fifth section, which requires you to disclose any ownership and managing control information, including individuals with an ownership or controlling interest in your organization, such as partners, officers, and directors.
7. Step 7: Complete the last sections, which include providing relevant certifications and signatures, as well as any additional supporting documentation required.
8. Step 8: Review your completed form, ensure all information is accurate, and make a copy for your records before submitting it to the appropriate Medicare Administrative Contractor (MAC) for processing.

Who needs 855 n?

1. The CMS 855N form is required for individuals or organizations looking to enroll in or make changes to their Medicare Supplier Billing privileges.
2. Entities such as Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers, pharmacies, nursing homes, home health agencies, and other healthcare providers may need to fill out the CMS 855N form.

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What is 855 n?

855 n is a form used by healthcare providers to enroll in the Medicare program.

Who is required to file 855 n?

Healthcare providers who want to participate in the Medicare program are required to file 855 n.

How to fill out 855 n?

855 n can be filled out online or on paper, and requires information such as provider details, practice location, and accreditation.

What is the purpose of 855 n?

The purpose of 855 n is to collect and verify information from healthcare providers who wish to enroll in the Medicare program.

What information must be reported on 855 n?

Information such as provider type, practice location, accreditation, contact information, and any previous enrollment in Medicare must be reported on 855 n.