CMS-855B 2011 free printable template

CMS-855B 07/11 Important For NPI purposes sole proprietors and sole proprietorships are considered to be Type 1 providers. MediCare enrollMent aPPliCation Clinics/group Practices and Certain other Suppliers CMS-855B See Page 1 to deterMine if you are CoMPleting the CorreCt aPPliCation. See Page 2 for inforMation on where to Mail thiS aPPliCation. See Page 35 to find a liSt of the SuPPorting doCuMentation that MuSt Be SuBMitted with thiS aPPliCation. DEPARTMENT OF HEALTH AND HUMAN SERVICES...

How to fill out CMS-855B

How to fill out CMS-855B

1. Obtain a copy of the CMS-855B form from the CMS website.
2. Read the instructions carefully before filling out the form.
3. Fill in the provider information in Section 1, including legal business name and tax identification number.
4. Complete Section 2 to provide additional information about the provider's practice and ownership.
5. Provide corresponding documentation as required for verification purposes in Section 3.
6. Review Sections 4 and 5 to ensure accurate information regarding billing and payment methods.
7. Sign and date the form in Section 6.
8. Submit the completed form and any required supporting documents to the appropriate Medicare administrative contractor.

Who needs CMS-855B?

1. The CMS-855B form is needed by providers or suppliers who wish to enroll in the Medicare program as a Medicare Part B provider.
2. It is typically required for individual practitioners, group practices, and suppliers of certain goods and services.

• Who needs the CMS Form 885B?
• What is the CMS Form 885B for?
• Is the Medicare Enrollment Application CMS-885B accompanied by any other forms?
• • How to fill out the CMS-885B Form?
  • Where do I send the completed CMS-885B Application Form?

Who needs the CMS Form 885B?

The 885B form is the Centers for Medicare and Medicaid Services (CMS) form also known as the Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers. There is a list of suppliers that are supposed to file the CMS-885B in order to commence the process of enrollment. These suppliers are:

• Ambulance Service Supplier

• Ambulatory Surgical Center

• Clinic/Group Practice

• Independent Clinical Laboratory

• Independent Diagnostic Testing Facility

• Intensive Cardiac Rehabilitation Supplier

• Mammography Center

• Mass Immunization

• Part B Drug Vendor

• Portable X-ray Supplier

• Radiation Therapy Center

What is the CMS Form 885B for?

The CMS Form 885B has been specifically designed for specific types of suppliers to enable them to apply for enrollment in the Medicare program or to update or amend their previously indicated information.  

Is the Medicare Enrollment Application CMS-885B accompanied by any other forms?

The Enrollment Application requires a list of supporting forms and may not be filed as a single document. All the mandatory attachments to the CMS-885B form are clearly defined on page 36 of the fillable application form itself.

However, here are the two commonly attached documents:

1. Form CMS-588 (Electronic Funds Transfer Authorization Agreement)

2. CMS Form 460 (Medicare Participating Physician or Supplier Agreement)

How to fill out the CMS-885B Form?

The voluminous 49-page form contains 17 sections and 2 attachments to fill out. Broadly put, the form requests basic identifying information, practice location, ownership interest, billing agency information, certification statement, etc.

Where do I send the completed CMS-885B Application Form?

Having completed the form and all the required attachments, the applicant should deliver them to the Medicare fee-for-service contractor operating in the relevant geographic location.

 

People Also Ask about

What is the difference between an 855O and 855I?

CMS-855I: For employed physician assistants (sections 1, 2, 3, 13, and 15). CMS-855R: Individuals reassigning (entire application). CMS-855O: All eligible physicians and non-physician practitioners (entire application). Same applications are required as those of new enrollees.

What is pecos login?

Log In. PECOS supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information.

How to do a reassignment of benefits in Pecos?

0:36 7:08 PECOS Reassignment through Individual Providers Enrollment YouTube Start of suggested clip End of suggested clip State select view manage reassignments on the reassignment. Report screen click manage reassignmentsMoreState select view manage reassignments on the reassignment. Report screen click manage reassignments. Select add a new reassignment.

What is cms855b?

Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers. Revision Date. 2021-03-01. O.M.B. #

Who can enroll in Pecos?

If you are one of these professionals then you must register with PECOS: Physician Assistants, Certified Clinical Nurse Specialists, Nurse Practitioners, Clinical Psychologists, Certified Nurse-Midwives, Clinical Social Workers.

How do I enroll in Pecos provider?

Log into PECOS enrollment system using your NPI User ID and Password. Note: Java Script must be enabled in your internet browser for PECOS to work properly. Click on “My Associates” to enroll as a Medicare Provider for the first time.

For pdfFiller’s FAQs

How can I modify CMS-855B without leaving Google Drive?

It is possible to significantly enhance your document management and form preparation by combining pdfFiller with Google Docs. This will allow you to generate papers, amend them, and sign them straight from your Google Drive. Use the add-on to convert your CMS-855B into a dynamic fillable form that can be managed and signed using any internet-connected device.

How do I execute CMS-855B online?

Completing and signing CMS-855B online is easy with pdfFiller. It enables you to edit original PDF content, highlight, blackout, erase and type text anywhere on a page, legally eSign your form, and much more. Create your free account and manage professional documents on the web.

How do I complete CMS-855B on an iOS device?

Download and install the pdfFiller iOS app. Then, launch the app and log in or create an account to have access to all of the editing tools of the solution. Upload your CMS-855B from your device or cloud storage to open it, or input the document URL. After filling out all of the essential areas in the document and eSigning it (if necessary), you may save it or share it with others.

What is CMS-855B?

CMS-855B is a form used by Medicare providers to enroll or update their information in the Medicare program. It is specifically designed for suppliers of durable medical equipment (DME), prosthetics, orthotics, and other items.

Who is required to file CMS-855B?

Any individual or entity that wishes to enroll or update their information as a supplier of DME, prosthetics, orthotics, or related services must file the CMS-855B form.

How to fill out CMS-855B?

To fill out CMS-855B, you need to provide accurate and complete information regarding your business structure, ownership, and services provided. The form must be filled out in compliance with the specific instructions provided by CMS and submitted electronically or via paper, as applicable.

What is the purpose of CMS-855B?

The purpose of CMS-855B is to facilitate the enrollment process for DME suppliers in the Medicare program and ensure that all necessary information is collected to provide proper reimbursement and compliance with regulations.

What information must be reported on CMS-855B?

The CMS-855B form requires the reporting of various information, including the supplier's legal business name, tax identification number, address, ownership information, types of services offered, and any other relevant details necessary for Medicare enrollment.