CMS-855A 2023 free printable template
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MEDICARE ENROLLMENT APPLICATION
INSTITUTIONAL PROVIDERSCMS855A
SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION.
SEE PAGE 5 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION.
SEE
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How to fill out CMS-855A
01
Obtain the CMS-855A application form from the CMS website or a regional CMS office.
02
Complete the identification section, providing your legal business name and any other required identifying information.
03
Fill out the general information section, including address, phone number, and type of provider.
04
Provide ownership and control information for your organization.
05
Complete the section for practice location details, including any secondary locations.
06
Answer all questions regarding prior participation in Medicare and any disciplinary actions.
07
If applicable, include any required documentation, such as tax identification numbers or licenses.
08
Sign and date the application to certify the information provided is correct.
09
Submit the completed application by mail or electronically, as instructed.
Who needs CMS-855A?
01
Any individual or entity that wishes to enroll as a Medicare provider, including physicians, non-physician practitioners, or institutional providers.
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What is CMS-855A?
CMS-855A is an application form used by Medicare providers to enroll in the Medicare program or to update their enrollment information.
Who is required to file CMS-855A?
Entities that want to enroll as Medicare providers, including individual practitioners, group practices, and certain organizations, are required to file CMS-855A.
How to fill out CMS-855A?
To fill out CMS-855A, you must provide detailed information about your practice, including provider information, ownership details, and tax identification information, ensuring all required sections are completed accurately.
What is the purpose of CMS-855A?
The purpose of CMS-855A is to gather necessary information for Medicare enrollment, ensuring that providers meet all regulatory requirements to bill Medicare for services.
What information must be reported on CMS-855A?
CMS-855A requires reporting of information such as provider identity, business structure, practice locations, billing information, and ownership details.
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