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60 Market Center Dr. ×103, Collierville, TN 38017
O: 901.316.5752TP: 855.344.8724F: 901.316.5760TF: 844.588.5560beneverepharmacy.general Prescription Referral Form
PATIENT INFORMATIONPRESCRIBER INFORMATIONPatient
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How to fill out tp 855
How to fill out tp 855
01
To fill out tp 855, follow these steps:
02
Start by providing your personal information, such as your name, address, and contact information.
03
Indicate whether you are an individual practitioner or a group practice, and provide any relevant details.
04
Fill in your National Provider Identifier (NPI), Medicare Identification Number (if applicable), and other identification numbers requested.
05
Specify the type of enrollment application you are submitting and fill in the corresponding fields.
06
Complete the disclosure of ownership and control interest section, including any relevant information about individuals or organizations with ownership or control interests in your practice.
07
Provide details about your medical practice, including the services you offer, your specialty, and any certifications or accreditations.
08
Answer questions about your medical education, training, and licensing.
09
If applicable, provide information about any Medicare or Medicaid sanctions or exclusions you have faced in the past.
10
Review the completed form for accuracy and make any necessary corrections.
11
Sign and date the form, and submit it according to the instructions provided.
Who needs tp 855?
01
TP 855 is needed by healthcare providers or organizations who wish to enroll or make changes to their enrollment information with Medicare.
02
This form is typically required for individual practitioners, group practices, clinics, hospitals, home health agencies, durable medical equipment suppliers, and other healthcare providers.
03
It is important to accurately complete and submit TP 855 to ensure proper enrollment and eligibility for Medicare benefits and reimbursements.
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What is tp 855?
tp 855 is a form used by Medicare providers to enroll, change or update their information.
Who is required to file tp 855?
All Medicare providers, suppliers, and entities are required to file tp 855.
How to fill out tp 855?
tp 855 can be filled out online through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS).
What is the purpose of tp 855?
The purpose of tp 855 is to enroll, update, or make changes to Medicare provider information.
What information must be reported on tp 855?
Information such as provider demographics, practice locations, ownership details, and accreditation must be reported on tp 855.
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