Get the free CMS-855A Medicare Enrollment Application

PRINTED: 09/12/2023 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

How to fill out cms-855a medicare enrollment application

How to fill out cms-855a medicare enrollment application

1. Obtain a blank CMS-855A form from the Centers for Medicare & Medicaid Services (CMS) website.
2. Fill in the applicant information section, including name, address, contact information, and Social Security number.
3. Provide information about your business entity, including the legal business name and tax identification number.
4. Complete the disclosure of ownership and control interest section, including information about all individuals with an ownership or controlling interest in the business.
5. Include information about any additional business locations that will be billing Medicare under the same tax identification number.
6. Sign and date the application form, attesting to the accuracy of the information provided.
7. Submit the completed CMS-855A form to the appropriate Medicare Administrative Contractor (MAC) for processing.

Who needs cms-855a medicare enrollment application?

1. Healthcare providers, such as medical practices, clinics, and other healthcare organizations, who wish to enroll in the Medicare program and bill Medicare for services rendered.

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What is cms-855a medicare enrollment application?

CMS-855A is the application form used by healthcare providers to enroll in the Medicare program as a Medicare Part A provider.

Who is required to file cms-855a medicare enrollment application?

Healthcare providers who want to enroll in the Medicare program as a Medicare Part A provider are required to file CMS-855A.

How to fill out cms-855a medicare enrollment application?

The CMS-855A application can be filled out online or by mail. Providers must provide accurate and up-to-date information about their practice, billing, and ownership.

What is the purpose of cms-855a medicare enrollment application?

The purpose of the CMS-855A application is to enroll healthcare providers in the Medicare program so they can bill Medicare for services provided to Medicare beneficiaries.

What information must be reported on cms-855a medicare enrollment application?

Providers must report information about their practice location, billing services, ownership, financial information, and compliance with Medicare regulations on the CMS-855A application.