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Section of form |
Helpful hints |
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Section 1: Basic information |
Section 1A: Reason for submitting this application Select the reason for submitting the application. Section 1B: What information is changing? If you are performing a change of information, please select the sections you are changing: • Required sections for the change of information are listed in the right column |
Section 2: Identifying information |
Section 2A: Supplier identification information Identify how your business is registered with the IRS: • If a checkbox identifying how the business is registered with the IRS is not completed, the supplier will be defaulted to proprietary Make sure the legal business name provided matches exactly as reported to the IRS. Correspondence address is the address we can contact the supplier directly: • Address cannot be a billing agent or agency's address or a medical management company Medical record correspondence address would be used for any medical record review requests. Section 2B: Type of supplier The organization must meet all Federal and State requirements for the type of supplier checked. If you are more than one type of supplier, submit a separate application for each type. Section 2C: Hospitals only This section does not apply if your hospital is enrolling a clinic that is not located within the hospital. If you are a hospital that plans to bill separately for each hospital department, ensure you separately list each department, Medicare identification number, and NPI. Section 2D: Physical therapy (PT) and occupational therapy (OT) groups only This section only applies to PT/OTs in groups (e.g., a group who solely consists of PT/OT providers). If any of the responses to the questions 2, 3, or 4 is "yes", you must submit a copy of the written agreement that gives the group exclusive use of the facility for PT/OT services. Section 2E: Accreditation for ambulatory surgical centers (ASCs) only If you are enrolling an ASC, provide accreditation information. Section 2F: Employer terminating employment arrangement with one or more physician assistants Complete this section if you are discontinuing the employment arrangement of a physician assistant. |
Section 3: Final adverse legal actions |
Section 3C: Final adverse legal action history Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. |
Section 4: Practice location information |
Section 4A: Practice location information If you or your organization sees patients in more than one practice location, copy and complete this section for each location. Be sure to include the date you saw your first Medicare patient at this location. You must indicate the type of practice location. Note: Your practice location must be the physical location where you render services to Medicare beneficiaries. Your practice location address cannot be a Post Office (P.O.) box, commercial mailbox, or a drop box. Section 4B: Remittance notices/special payments mailing address Provide address where payment information (e.g., remittance notices, non-routine special payments) should be sent. Section 4C: Medicare beneficiary medical records storage address P.O. boxes and drop boxes are not acceptable addresses for the medical record storage location. Section 4D: Rendering services in patients' homes If you are adding or deleting an entire state, simply check the box and specify the state. Otherwise, list the city/town(s) and/or ZIP code, if not servicing the entire city/town. Section 4E: Base of operations address for mobile or portable suppliers The base of operations is the location from where personnel are dispatched, where mobile/portable equipment is stored, and when applicable, where vehicles are parked when not in use. Section 4F: Vehicle information This section is applicable to mobile vehicles where health care services are provided: • This section is not applicable to vehicles that are used only to transport medical equipment (e.g., transported in a van, but used in a fixed setting) If more than four vehicles are used, copy this section and complete it for each additional vehicle. If you are initially reporting or adding an entire state/territory, check the applicable box in 4G1 and furnish the state/territory. If you are not servicing an entire state/territory, provide the city/town or county where you provide services: • Only list the ZIP codes if you are not servicing the entire city/town or county |
Section 5: Ownership interest and/or managing control information (organizations) |
Section 5A: Organization with ownership interest and/or managing control - Identification information This section only applies to organizations. Any organization that exercised operational or managerial control over the provider or conducts the day-to-day operations, is a managing organization. Examples of organizations: • Governmental, tribal, non-profit charitable, religious organizations, corporations (including non-profit), partnerships, LLCs, etc. Organization need not have an ownership interest in the provider. Supplier must submit an organizational structure diagram/flowchart identifying all the entities listed in section 5 and their relationships with the supplier and each other. If more than one organization has ownership interest and/or managing control, copy and complete this section for each organization. Section 5B: Final adverse legal action history Complete this section by answering "Yes" or "No" if the organization has ever had a final adverse legal action imposed against it. If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. |
Section 6: Ownership interest and/or managing control information (individuals) |
Section 6A: Individuals with ownership interest and/or managing control - Identification information The name, date of birth, and social security number of each person listed must coincide with the individual's information reported to the Social Security Administration. Authorized officials: • Must identify one other relationship of 5% or greater direct/indirect owner, partner, or director/officer • If this application is for initial enrollment, ensure you complete and sign in section 15 Delegated officials: • Must identify one other relationship but can select managing employee as other relationship • If this application is for initial enrollment, ensure you complete and sign in section 15 If more than one individual has ownership interest and/or managing control, copy and complete this section for each individual. Section 6B: Final adverse legal action history Complete this section by answering "Yes" or "No" if the individual in 6A has ever had a final adverse legal action imposed against him/her. If yes, make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. |
Section 8: Billing agency/agent information |
A billing agency is a company or individual you contract with to prepare and submit your claims: • If you are using a billing agency, you are responsible for the claims submitted on your behalf. |
Section 12: Supporting documentation information |
See below for required supporting documents Mandatory for providers/suppliers, if applicable: • Voided check or bank letterhead must accompany above application and needs to be in the group's legal business name • Medicare Enrollment Application – Physicians and Non-Physician Practitioners (CMS-855I ) for rendering providers• Medicare Enrollment Application - Medicare Participating Physician or Supplier Agreement (CMS-460 )• Written confirmation from the IRS • Copy of IRS determination letter if you are registered as non-profit • Copy of all adverse legal action documents (e.g., notifications, resolutions, and reinstatement letters) • Copy of attestation for government entities or tribal organizations • Organizational structure diagram/flowchart identifying all of the entities listed in section 5 • Written statement from the bank, if payment due to a provider is being sent to a bank (or other financial institution) with whom the provider has a lending relationship (e.g., loan), that the bank has agreed to waive its right of offset for Medicare receivables • Copy of all mobile vehicle registrations Independent diagnostic testing facility (IDTF): • Copy of all documents verifying state licenses or certifications of the laboratory director or non-physician practitioner personnel of an independent clinical laboratory • Copy of all documentation verifying IDTF supervisory physician proficiency and/or state licenses or certification for IDTF non-physician personnel • Proof of board certification for all supervising physicians as noted on the LCD article • Copy of comprehensive liability insurance policy Ambulance: • Copy of all ambulances' licenses • Copy of Federal aviation administration (FAA) 135 certificate (air ambulance suppliers only) Opioid treatment programs (OTPs): • Copy of opioid treatment approval letter • Copy of opioid treatment operating certificate |
Section 13: Contact person information |
Captures the person we will contact about the application. Be sure to include all information, including the e-mail address. |
Section 14: Penalties for falsifying information on this application |
This section explains the penalties for deliberately furnishing false information: • Read this section as it outlines criminal penalties and civil liability on individuals who knowingly furnish false information |
Section 15: Certification statement |
Section 15B: Authorized official signature(s) For initial enrollments, all individuals listed in section 6 as an authorized official, must sign section 15B. All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures are not acceptable. Section 15D: Delegated official signature(s) For initial enrollments, all individuals listed in section 6 as a delegated official, must sign section 15D. All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures are not acceptable. |
Attachment 1: Ambulance service suppliers |
A. Ambulance supplier transport type Indicate which ambulance service(s) you intend to provide. B. Geographic area Provide the city/town, and/or county, state/territory, and ZIP code for all locations where the ambulance company renders services: • List ZIP codes only if they are not within the entire city/town If the ambulance company has vehicles garaged within a different Medicare contractor's jurisdiction, a separate form must also be submitted to that contractor. C. State license information Crew members are required to maintain continuing education requirements. Evidence of this must be retained and submitted if requested by us. D. Vehicle information Provide vehicle information on each of the vehicles used by the ambulance company: • If there is more than one vehicle, copy this section and complete it for each additional vehicle Attach a copy of each vehicle registration. If qualifying as an air ambulance, provide: • Written statement from the airport where the aircraft is hangered • Copy of the FAA 135 Certificate If the aircraft is leased, provide a copy of the lease agreement. |
Attachment 2: Independent diagnostic testing facility (IDTF) performance standards |
If you perform diagnostic tests, other than clinical laboratory or pathology tests, and are required to enroll as an IDTF, you must complete this attachment. A. Standards qualifications Provide the date the IDTF met all the listed CMS standards in order to obtain and maintain its billing privileges: • Refer to 42 CFR Section 410.33(g) for the full text on the listed standards • Pursuant to 42 CFR §§ 424.530(a)(1)/(18) and 424.535(a)(1)/(23), the Centers for Medicare & Medicaid Services (CMS) may, respectively, deny or revoke an IDTF's enrollment if it violates any applicable standard in § 410.33(g) B. CPT-4 and HCPCS codes List all CPT-4 and HCPCS codes for which the IDTF will bill Medicare: • Do not report codes for diagnostic tests that are surgical in nature and must be performed in a hospital or ambulatory surgical center • Do not report clinical laboratory and pathology codes Update this list any time there is a change, add, or removal to the codes being billed. C. Interpreting physician information If the interpreting physicians will bill separately from the IDTF, mark the box that this section does not apply. Otherwise, complete this section for each interpreting physician. All interpreting physicians must be currently enrolled in the Medicare program. If there are more than two interpreting physicians, copy this section and complete it for each additional interpreting physician. D. Personnel (technicians) who perform tests Complete this section for all non-physician personnel who perform tests for this IDTF. Technicians must meet qualifications for the codes listed on the application/existing file. If there are more than two technicians, copy this section and complete it for each additional technician. E. Supervising physicians All IDTFs must report at least one supervisory physician and at least one supervising physician must perform the supervision requirements stated in 42 C.F.R 410.32(b)(3). All supervisory physician(s) must be currently enrolled in Medicare. Select the appropriate type of supervision provided by the reported physician for the tests performed by the IDTF. General supervising physicians cannot supervise for more than three IDTF's at one time. Must provide Supervising physicians that meet qualifications for the CPT code level of supervision requirements. Ensure all three boxes for assuming responsibility are marked between the Supervising Physicians. Indicate if the supervising physician provides supervision at any other IDTF and provide the information for the IDTF (if applicable). All supervising physicians must complete and sign the attestation statement in this section. Copy this section and complete it for each supervising physician. All signatures must be handwritten or an eligible digital signature (e.g., DocuSign, AdobeSign), as well as dated. Stamped signatures are not acceptable. |
Attachment 3: Opioid treatment program personnel |
The OTP must include the following information for all employees and contracted staff, whether W-2 or not, who are legally authorized to order controlled substances, whether or not the individual is currently ordering at the OTP facility. A. Ordering personnel identification Copy and complete this section if more than three OTP ordering personnel need to be reported. B. Dispensing personnel identification Copy and complete this section if more than three OTP dispensing personnel need to be reported. |
