Completing the Medicare Enrollment Application - Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) application

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Home ► PE Tips and tutorials ► Completing the Medicare Enrollment Application - Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) application

Last Modified: 3/25/2024 Location: FL, PR, USVI Business: Part B

Completing the Medicare Enrollment Application - Enrollment for Eligible Ordering/Certifying Physicians and Other Eligible Professionals (CMS-855O) application

Physician and non-physician practitioners can apply to register for the sole purpose of ordering and referring items or services to Medicare beneficiaries or make a change in their registration using the Enrollment for Eligible Ordering or Certifying Physicians and Other Eligible Professionals (CMS-855O external pdf file

) application.

Note: These physicians and non-physician practitioners do not and will not submit claims to a Medicare Administrative Contractor (MAC) for the services they furnish for reimbursement.

The chart below is designed to provide additional instructions on completing the enrollment application. Please make sure to follow the guidelines listed on the application.

Note: Once you complete the application, you can either upload the application on the Provider Enrollment Gateway or mail the application to us.

Section of form	Helpful hints
Section 1: Basic information	Section 1A: Reason for submitting this application Select the reason for submitting the application Section 1B: Reason you are enrolling solely to order or certify Choose only one reason from group 1 or group 2
Section 2: Identifying information	Section 2A: Personal information List the individual's name as it appears with the social security administration (SSA) Section 2B: Educational information Provide your medical or professional school and year of graduation Section 2C: License or certification information Provide any active license, certification, or Drug Enforcement Agency (DEA) registration information
Section 3: Final adverse legal action	Section 3C: Final adverse legal action history Make sure to include a copy of all final adverse legal action documentation and resolution, if applicable
Section 4: Medical specialty information	Section 4A: Physician specialty Select your primary physician specialty: • You must meet all federal and state requirements for the specialty type selected Section 4B: Eligible professional or other non-physician specialty type Select your primary non-physician specialty type: • You must meet the licensing, education, and work experience requirements Note: You can only select one physician or non-physician specialty type.
Section 5: Correspondence mailing address	Information provided should be the contact information for the individual practitioner listed in section 2
Section 6: Contact person information	Person listed in this section is the only person, other than the practitioner, we are permitted to speak with regarding the application Be sure to include all contact information, including the email address
Section 7: Penalties for falsifying information on this application	Be sure to read this section as it outlines criminal penalties and civil liability on individuals who knowingly furnish false information
Section 8: Certification statement and signature	Individual practitioner must sign this application: • Authority to sign on your behalf can not be delegated Signatures must be handwritten or an eligible digital signature
Additional guidance	Enrolling as an ordering and referring provider is considered a national status. If you move states, make sure to update your enrollment with current license information. Revalidation is not required for ordering and referring providers.

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