Last Modified: 4/5/2023
Location: FL, PR, USVI
Business: Part B
Reason for submitting this application.
• Select one of the reasons
Did you check only one box on page 4, Section 1A (Basic Information)?
• Yes
Did you fill in the “required sections” denoted to the right side of the box you checked?
• Yes
Did you check one or more boxes on page 4, Section 1B (Basic Information) if you are making changes to a current enrollment?
• Yes
Did you fill in the “required sections” denoted to the right side of each box you checked?
• Yes
Did you fill in your personal information on page 5 in Section 2A/2B/2C, (Identifying Information), relative to yourself as well as to your license and certification information?
• Yes
Types of licenses required are:
• Professional license
Types of certifications required are:
• CNM
• CNS
• NP
Did you provide your correspondence address (not a billing agency’s address) for Section 2D, on page 6?
• Yes
Did you provide your Medical Record correspondence address (not a billing agency’s address) for Section 2E, on page 6?
• Yes
Note: This address cannot be your billing agency address.
Did you complete questions 1-4 in Section 2F (Resident Information) on pages 6-7, if you are currently in an approved training program as a resident?
• Yes
If you are not in an approved training program, did you answer “no” to questions 3 and 4?
• Yes
If you are a physician did you designate your primary specialty (only one) and your secondary specialties (one or more) on page 7, Section 2G (Physician Specialties).
• Yes
If you checked Diagnostic Radiology as your specialty, and you will be billing Medicare for the technical component of the diagnostic tests, did you also complete a CMS-855B enrollment form as an independent diagnostic testing facility (IDTF)?
• Yes
If you are a non-physician, did you designate your non-physician specialty on page 8, Section 2H.
• Yes
Note: An additional CMS-855I must be completed for each non-physician specialty type.
If you are a physician’s assistant, did you fill in the required information on page 8, Section I?
• Yes
Note: In Section 2I, ensure that the name corresponding with the employer’s NPI is the legal business name as reported to the IRS and that it matches exactly. This includes any spacing or punctuation. If not, contact NPPES (
https://nppes.cms.hhs.gov/#/ 
) and request the update.
If you are a Clinical Psychologist did you complete Section 2J1 on page 9 and attach a copy of the degree?
• Yes
If you are a Psychologist Billing Independently did you complete Section 2J2 (questions A – D2) on page 9?
• Yes
Did you complete Section 2K (questions 1-5) on page 10, if you are a physical or occupational therapist in private practice?
• Yes
If you responded “yes” to any question numbered 2-4, did you attach a copy of the lease agreement for your facility usage?
• Yes
Did you respond “yes” or “no” regarding whether or not you are an employee of a Medicare skilled nursing facility (SNF) or an employee of another entity that has an agreement to provide nursing services to a SNF in Section 2K on page 10 if you are a Clinical Nurse/Nurse Practitioner?
• Yes
If you answered “yes,” did you provide the name and address of the applicable SNF?
• Yes
Did you report any Final Adverse Actions/Convictions that have been imposed against you in Section 3 (Final Adverse Actions/Convictions) page 11?
• Yes
If yes, did you attach a copy of the final adverse action documentation and its resolution?
• Yes
Note: Your application will be considered incomplete if the information is missing or you enter “not applicable.”
Did you complete Section 4A on page 12, if you are the sole owner of a professional corporation, a professional association, or a limited liability company intending to bill Medicare through this business entity?
• Yes
Note: Section 4A1– Ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. If not, contact NPPES (
https://nppes.cms.hhs.gov/#/ ) and request the update.
Has your organization, under any current or former name or business identity ever had any final adverse actions that have been imposed against it (page 13, Section 4A2 under "Final Adverse History," questions a & b)?
• Yes
If yes, did you attach a copy of the final adverse action documentation and its resolution?
• Yes
Did you provide your employer identification number (EIN) in Section 4A3 (Employer ID Number Information), page 13 in order for your Medicare payments to be reported under your EIN?
• Yes
Did you fill in the appropriate spaces in Section 4B (changes/additions/deletions) on page 14 regarding your solo practice or your organization’s practice location(s)?
• Yes
Note: If you as a sole practitioner or your organization sees patients in more than one location, complete this section for each location.
Did you fill in Section 4C on page 15 regarding your option to have your special payment address mirror your practice location address, or to be different from that?
• Yes
Did you fill in Section 4D on page 15 regarding your option to have your medical records storage address mirror your practice location address, or to be different from that?
• Yes
Did you fill in the requested information on page 16; Section 4E, for all locations where health care services are rendered in patients’ homes?
• Yes
Did you complete 4F individual reassignment/affiliation information?
• Yes
Did you include the name(s) of all managing employees in Section 6A on page 18? A managing employee means a general manager, business manager, administrator, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts, the day-to-day operations of the supplies, either under contract or through some other arrangement, regardless of whether the individual is a W-2 employee or the supplier.
• Yes
Note: If there is more than one managing employee, copy and complete this section as needed.
Did you identify any final adverse actions that have been imposed against those individuals in 6A (Final Adverse Actions/Convictions) page 18 in 6B?
• Yes
If yes, did you attach a copy of the adverse legal action documentation and resolution?
• Yes
Did you complete Section 8 on page 19 with information specific to the billing agency you utilize?
• Yes
Note: If you do not use a billing agency, you can continue with Section 13 on page 21). Make sure that you have first checked the box stating, “Check here if this section does not apply.”
Did you read Section 12 on page 20 to ensure that you have submitted correct and complete supporting documentation?
• Yes
Did you complete Section 13 on page 21 with the contact person information?
• Yes
Did you read Section 14 on page 22 to ensure your understanding of the penalties for falsifying Medicare information?
• Yes
Did you complete the certification statement in Section 15 (page 23)?
• Yes
Note: For electronic fund transfer (EFT), include CMS-588 for initial enrollments and/or if you are making changes to an existing Medicare provider number that has not already been set up for EFT. Remember to submit a voided check and/or confirmation of account information on bank letterhead.
The following chart describes when and how First Coast will contact providers based on the contact information provided in your enrollment application.
Contact Type |
During the Enrollment Process |
Once Provider/Supplier Is Enrolled |
Contact address |
Used as a first contact for all additional information requests and to notify groups and individual practitioner of approval/denial into the Medicare program. |
N/A |
Correspondence address |
Used for additional information requests and to notify groups and individual practitioner of approval/denial into the Medicare program if the contact information on the application is incomplete. |
N/A |
Pay-to address |
Used to send remittance to providers. |
Used to request additional claim information and/or to send remittance advices and checks to providers. Note: Upon request from the provider/supplier, requests for additional claim information may be sent to the practice address. |
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