application in order to initiate the enrollment process and, as applicable, wish to reassign their benefits under § 424.80.
Section of form |
Helpful hints |
|---|---|
Section 1: Basic information |
Section 1A: Reason for submitting this application Select the reason for submitting the application. This includes establishing, terminating, or changing reassignments. 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: Personal identifying information |
Section 2A: Individual information List the practitioner's name as it appears with the Social Security Administration (SSA): • you had a name change, your name must be updated with the SSA and National Plan and Provider Enumeration System (NPPES) before you can update your Medicare enrollment record Section 2B: License/certification/registration information Provide your license, certification, and Drug Enforcement Agency (DEA) registration information, if applicable. Is this a compact license: Yes or No. Section 2C: New patient information Answer whether you are currently accepting new Medicare patients. Section 2D: Correspondence mailing address Must be an address where we can contact the individual practitioner directly: • cannot be the address of a billing agency, management services organization, or the supplier's representative Section 2E: Medical record correspondence address (MRCA) Must be an address we can contact the applicant regarding medical records once the supplier is enrolled in Medicare: • cannot be the address of a billing agency, management services organization, or the supplier's representative • MRCA is not applicable for an individual who is only reassigning benefits to a group/organization Section 2F: Resident information If you are a resident or in a fellowship program, answer the questions listed, including the name of the teaching hospital/facility. Section 2G: Physician specialty If you have more than one specialty: • "P" for primary: • You can only have one primary specialty • "S" for secondary specialties You must meet all Federal and State requirements for each specialty. If you selected "diagnostic radiology" as your specialty and bill for the technical component of diagnostic tests, you may need to complete a Medicare Enrollment Application - Clinics and Group Practices and Other Suppliers (CMS-855B) application to enroll as an independent diagnostic testing facility (IDTF). Answer the acupuncture question. Section 2H: Eligible professional or other non-physician specialty type Select your non-physician specialty: • must meet the licensing, educational, and work experience requirements If you need to enroll for more than one non-physician specialty type, you must complete a separate application for each specialty. Answer the acupuncture question. Section 2I1: Clinical psychologists You must hold a doctoral degree in psychology: • of degree must be submitted with the application Section 2I2: Psychologists billing independently You must answer the questions related to billing independently. Section 2J: Physical/occupational therapist information Required for physical and occupational therapist in private practice: • required for physical or occupational therapist who are reassigning all their benefits to a group or organization Section 2K: Clinical nurse/nurse practitioner information This section applies if you are an employee of a Medicare skilled nursing facility (SNF) or of another entity that has an agreement to provide nursing services to a SNF. |
Section 3: Final adverse legal actions |
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: Business information |
Section 4A1: Corporations, associations, and limited liability company Provide the business structure, your legal business name as reported to the IRS, tax identification, Medicare identification number (if issued), and type 2 NPI. Section 4A2: Final adverse legal action history Make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. Section 4A3: Sole proprietor/ Sole proprietorship Be sure to furnish IRS documentation showing your employer identification number (EIN). Section 4B: 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. Each location must be verified. 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 4C: Remittance notices/special payments mailing address Provide address where payment information (e.g., remittance notices, non-routine special payments) should be sent. Section 4D: Medicare beneficiary medical records storage address P.O. boxes and drop boxes are not acceptable addresses for the medical record storage location. Section 4E: 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. If you are changing information in this section, make sure to check the change box and provide effective date Section 4F: Individual/organization/group receiving the reassigned benefits Furnish the requested information about each group/organization/individual to which you will reassign your benefits: • section fully replaces the Medicare Enrollment Application - Reassignment of Medicare Benefits (CMS-855R). The Reassignment of Medicare Benefits (CMS-855R) application has been terminated Section 4F1: Individual practitioner receiving reassigned benefits identification If the reassignment is to an individual or sole proprietor, please supply information in this section: • the initial enrollment application is not complete and a provider transaction access number (PTAN) has not been issued, write "pending" in the Medicare identification number field Section 4F2: Organization/group receiving reassigned benefits identification If the reassignment is to an organization, please supply the information in this section: • the initial enrollment application is not complete and a PTAN has not been issued, please write "pending" in the Medicare identification number field Section 4F3: Primary practice location(s) (optional) Identify the primary/secondary practice location where the individual practitioner will render services most of the time: • locations provided must be currently enrolled or enrolling in Medicare |
Section 6: Managing employee information |
Section 6A: Managing employee identifying information If the individual listed in section 2A is the managing employee, please mark the box: I am the managing employee and skip to section 8. If there is more than one managing employee, you must copy this section and complete it for each managing employee. Section 6B: Final adverse legal action history For each individual listed in section 6A, there must be an accompanying section 6B. Attach a copy of the final adverse legal action documentation and resolution, if applicable. |
Section 8: Billing agency information |
A billing agency is a company or individual you contract with to prepare and submit your claims: • 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: • practitioner and clinical nurse specialist: • National certification: For certifying bodies, please review our Nurse practitioner article • Verification of master's degree in nursing or Doctor of Nursing Practice (DNP) degree • nurse midwife: • Copy of your certification as a nurse-midwife • psychologist: • Copy of your doctoral degree in psychology • If your degree is in philosophy or education and does not specify a specific area of psychology, please include your graduate school transcripts indicating the concentration of study • • If you have a provisional license, we will also require a copy of your master's or doctoral degree in audiology • assistant, nurse practitioner, and clinical nurse specialist who provide acupuncture services: • Copy of acupuncture certification • Proof of educational requirements • and family therapists: • Documentation to demonstrate at least 2 years or 3,000 hours of post master's clinical supervised experience in marriage and family therapy • health counselors: • Documentation to demonstrate at least 2 years or 3,000 hours of post master's clinical supervised experience in mental health counseling |
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: • this section as it outlines criminal penalties and civil liability on individuals who knowingly furnish false information |
Section 15: Certification statement and signature |
Section 15: Certification statement and signature Signatures must be handwritten or an eligible digital signature. Section 15B: Signature and date Individual practitioner must sign this application: • to sign on your behalf can not be delegated Section 15C: Delegated or authorized official of individual/organization/group certification statement and signature If the individual is reassigned his/her benefits, a current authorized or delegated official must sign. |
Additional guidance |
If you plan to bill Medicare for your services, a Medicare Enrollment Application - Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588 ) is required:• is not required for an individual who is only reassigning benefits to a group/organization • some cases, a site visit may be required. To prevent processing impacts to your application, providers must be operational when the application is submitted, and site visit is performed |
