Completing the Medicare enrollment CMS-855I application
Physicians and non-physician practitioners
All physicians and non-physician practitioners must complete the Medicare Enrollment Application - Physicians and Non-Physician Practitioners (CMS-855I) application in order to initiate the enrollment process and, as applicable, wish to reassign their benefits under § 424.80.
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 |
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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:
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Section 2: Personal identifying information |
Section 2A: Individual information List the practitioner's name as it appears with the Social Security Administration (SSA):
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:
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:
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:
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:
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:
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:
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. Each location must be verified. 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 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 4F1: Individual practitioner receiving reassigned benefits identification If the reassignment is to an individual or sole proprietor, please supply information in this section:
Section 4F2: Organization / group receiving reassigned benefits identification If the reassignment is to an organization, please supply the information in this section:
Section 4F3: Primary practice location(s) (optional) Identify the primary / secondary practice location where the individual practitioner will render services most of the time:
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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:
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Section 12: Supporting documentation information |
See below for required supporting documents:
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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:
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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:
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:
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