CMS-855I - Medicare Enrollment Application

CMS-855I Medicare Enrollment Application - Physicians and Non-Physician Practitioners PURPOSE: This form is used by individual physicians and eligible professionals to enroll in the Medicare program, revalidate existing enrollment, make changes to enrollment information, or voluntarily terminate Medicare participation. KEY TERMINOLOGY: - NPI (National Provider Identifier): A unique 10-digit identification number required for all healthcare providers. Obtained from NPPES (National Plan and Provider Enumeration System). - PTAN (Provider Transaction Access Number): Medicare-specific billing number assigned by the MAC after successful enrollment. - MAC (Medicare Administrative Contractor): Regional contractors that process Medicare claims. Different MACs cover different geographic jurisdictions. - SSN (Social Security Number): Required for individual enrollment identification and IRS reporting. - TIN (Tax Identification Number): For business entities, this is the EIN (Employer Identification Number). - DEA (Drug Enforcement Administration): Registration required for providers who prescribe controlled substances. - Reassignment of Benefits: Legal arrangement where a practitioner assigns their Medicare payments to be made to a group practice or employer instead of directly to themselves. - PECOS (Provider Enrollment, Chain, and Ownership System): CMS's online enrollment system where this information is stored. ELIGIBLE PROVIDER TYPES: Physicians: MD (Doctor of Medicine), DO (Doctor of Osteopathy), DPM (Doctor of Podiatric Medicine), DDS/DMD (Dentists - limited services), DC (Chiropractors - limited services), OD (Optometrists - limited services) Non-Physician Practitioners: PA (Physician Assistant), NP (Nurse Practitioner), CNS (Clinical Nurse Specialist), CRNA (Certified Registered Nurse Anesthetist), CNM (Certified Nurse Midwife), CSW (Clinical Social Worker), CP (Clinical Psychologist), PT (Physical Therapist), OT (Occupational Therapist), SLP (Speech-Language Pathologist), Audiologist, RD (Registered Dietitian/Nutritionist), Certified Anesthesiologist Assistant SUBMISSION REASONS (Section 1): - Initial Enrollment: First time enrolling in Medicare - Revalidation: Periodic re-verification required every 5 years or when requested by CMS - Reactivation: Restoring a deactivated enrollment - Change of Information: Updating existing enrollment data (address, specialty, reassignment, etc.) - Voluntary Termination: Ending Medicare participation PROCESSING INFORMATION: - Submit to the MAC for the state where services will be rendered - Processing time typically 45-60 days for complete applications - Incomplete applications will be returned with a request for additional information - Effective dates vary: Initial enrollment effective from the filing date or later; changes effective from the date specified or filing date COMMON ERRORS TO AVOID: - Missing or incorrect NPI number - Unsigned or undated certification statement - Missing required supporting documents (DEA, state license, etc.) - Incorrect MAC jurisdiction for practice location - Incomplete Section 4F when reassigning benefits RELATED FORMS: - CMS-460: Medicare Participating Physician/Supplier Agreement - CMS-588: Electronic Funds Transfer (EFT) Authorization Agreement - CMS-855R: Reassignment of Medicare Benefits (alternative to Section 4F) - CMS-855B: Used for clinics, group practices, and organizations (not individual practitioners)

SECTION 2: PERSONAL IDENTIFYING INFORMATION (Continued)

D. CORRESPONDENCE MAILING ADDRESS

Change Effective Date:

Attention (optional)
Address Line 1
Address Line 2
City	State	ZIP+4
Telephone	Fax	E-mail

E. MEDICAL RECORD CORRESPONDENCE ADDRESS

Same as 2D - skip this section

Change Effective Date:

Attention (optional)
Address Line 1
Address Line 2
City	State	ZIP+4
Telephone	Fax	E-mail

F. RESIDENT INFORMATION

Resident = individual in an approved medical residency program.

1. Hospital/Facility where you are a resident:

Name
Address
City	State	ZIP+4

2. Services part of residency requirements?	Yes No	Completion Date:
3. Render services at other facilities?	Yes No
4. Other location services part of residency?	Yes No

CMS-855I (05/23) Page 3

SECTION 2: PERSONAL IDENTIFYING INFORMATION (Continued)

SECTION 3: FINAL ADVERSE LEGAL ACTIONS

Report all adverse actions regardless of expungement or pending appeals.

A. Convictions (10 years): Felonies; first offender/deferred adjudication; misdemeanors re: Medicare/Medicaid, patient abuse, fraud, controlled substances, obstruction.

B. Exclusions/Revocations: License revocation/suspension; accreditation issues; OIG exclusion; Federal debarment; CMP; Medicaid termination.

C. Have you had any adverse legal action imposed? YES - list below NO - skip to Section 4

FINAL ADVERSE LEGAL ACTION	DATE	ACTION TAKEN BY

CMS-855I (05/23) Page 5

SECTION 4: BUSINESS INFORMATION

No private practice, reassign ALL benefits - complete 4F only
Private practice AND reassign benefits - complete 4A-4F
Private practice, NO reassignment - complete 4A-4E

A. PRIVATE PRACTICE BUSINESS INFORMATION

Business Structure: Proprietary Non-Profit Disregarded Entity

1. Corporations, Associations, LLC

Legal Business Name (as reported to IRS)
Tax ID (TIN)		Medicare ID (PTAN)		NPI (Type 2)

2. Business Adverse Legal Actions: YES NO

FINAL ADVERSE LEGAL ACTION	DATE	ACTION TAKEN BY

3. Sole Proprietor - Pay under SSN Pay under EIN:

B. PRACTICE LOCATION

Skip if reassigning 100% of benefits. Complete for each location.

Change Add Remove Effective:

Practice Location Name (DBA)
Street Address Line 1
Street Address Line 2
City	State	ZIP+4
Telephone	Fax	E-mail
PTAN for this location	First Medicare patient date

Primary location? Yes No

Type: ASC Business Office Home Office Hospital IHS/Tribal Private Office SNF Other:

CMS-855I (05/23) Page 6

SECTION 4: BUSINESS INFORMATION (Continued)

C. REMITTANCE/SPECIAL PAYMENTS ADDRESS

Mail to Practice Location (4B) Mail to Correspondence (2D)

Change Effective:

Address Line 1
Address Line 2
City	State	ZIP

D. MEDICAL RECORDS STORAGE

Stored at practice location (4B) - skip

Add Remove Effective:

1. Paper: Yes No

Facility Name		Address
City		State		ZIP

2. Electronic: Yes No Site:

E. HOME SERVICES

Effective:

1. Additions: Entire State:

City/Town	County	State	ZIP

2. Deletions: Entire State:

3. Comments:

F. REASSIGNMENT OF BENEFITS

Both parties must be enrolled before reassignment takes effect.

1. Individual Receiving Reassigned Benefits:

Change Add Terminate Effective:

First Name		MI		Last Name		Suffix
SSN		EIN		PTAN		NPI

2. Organization/Group Receiving Benefits:

Change Add Terminate Effective:

Organization Legal Business Name
TIN		PTAN		NPI

3. Primary Practice Location (Optional):

Change Add Remove Effective:

Location Name (DBA)	Address
City	State	ZIP
PTAN	NPI

CMS-855I (05/23) Page 7

SECTION 6: MANAGING EMPLOYEE

Skip if reassigning 100% of benefits.

I am the managing employee - skip to Section 8

A. Change Add Remove Effective:

First Name	MI	Last Name	Suffix
SSN	DOB	PTAN	NPI
Phone	Fax	E-mail

Relationship: Contracted W-2

B. Adverse Legal Actions: YES NO - skip to Section 8

FINAL ADVERSE LEGAL ACTION	DATE	ACTION TAKEN BY

SECTION 8: BILLING AGENCY

Does not apply - skip to Section 12

Change Add Remove Effective:

Legal Business Name
DOB (if individual)	TIN/SSN
DBA Name
Address
City	State	ZIP
Phone	Fax	E-mail

SECTION 12: SUPPORTING DOCUMENTATION

Submit if applicable:

Adverse legal action documentation

CMS-460 Medicare Participating Agreement

CMS-588 EFT Authorization (with voided check)

IRS TIN/LBN confirmation (CP-575)

IRS Form 8832 (if Disregarded Entity)

IRS 501(c)(3) (if non-profit)

Acupuncture certification/credentials

SECTION 13: CONTACT PERSON (Optional)

Assign individual in 2A as contact

Change Add Remove Effective:

First Name	MI	Last Name	Suffix
Address
City	State	ZIP
Phone	Fax	E-mail
Relationship

CMS-855I (05/23) Page 8

SECTION 15: CERTIFICATION STATEMENT AND SIGNATURE

As an individual practitioner, you are the only person who can sign this application.

A. CERTIFICATION STATEMENT

Under penalty of perjury, I certify:

Information is true, correct, and complete.
I authorize MAC to verify information and will notify of changes per 42 C.F.R. 424.516.
I have read and understand the Penalties for Falsifying Information.
I agree to abide by Medicare laws, regulations, and program instructions.
Neither I nor any managing employee is currently sanctioned/excluded.
Overpayments may be recouped through withholding of future payments.
My Medicare ID can only be used by me or enrolled providers with reassignment.
I will not present false or fraudulent claims.
I am the individual practitioner applying and this is my signature.

B. SIGNATURE AND DATE

First Name (Print)

Last Name (Print)

Suffix

Practitioner Signature:

Date Signed

Application MUST be signed and dated to process.

C. DELEGATED/AUTHORIZED OFFICIAL CERTIFICATION

Complete only if accepting/terminating/changing reassignment in Section 4F.

Under penalty of perjury, I certify the information is true, accurate, and complete.

Official First Name (Print)

Last Name (Print)

Suffix

Delegated/Authorized Official Signature:

Date Signed

Application MUST be signed and dated to process.

PRIVACY ACT STATEMENT

Authority: Sections 1102(a), 1128, 1814(a), 1815(a), 1833(e), 1871, 1886(d)(5)(F) of the Social Security Act.

Purpose: Information entered into PECOS for identity, qualifications, practice locations, ownership, billing, reassignment, EFT, and NPI data.

Routine Uses: Support CMS contractors; assist Federal/state agencies; research; litigation; fraud investigation.

PRA Disclosure: OMB No. 0938-1355 (Expires 05/2026). Estimated completion time: 0.5-3 hours.

CMS-855I (05/23) Page 9

	New enrollee in Medicare	All sections
	Currently enrolled to order/certify, want to enroll as Individual Practitioner	All sections
	Enrolling with another MAC	All sections
	Revalidating Medicare enrollment	All sections
	Reactivating Medicare enrollment	All sections
	Reporting a change to enrollment (includes reassignment)	Section 1B
	Voluntarily terminating. Effective date:	1A, 2A, 13, 15

	Personal Identifying Information	1,2A,3,12,13,15
	Final Adverse Legal Actions	1,2A,3,12,13,15
	Medical Specialty Information	1,2A,2G/H,3,4,12,13,15
	Practitioner Specific Information	1,2A,2B-K,3,12,13,15
	Reassignment of Benefits Information	1,2A,4F,12,13,15
	Private Practice Business Information	1,2A,3,4A,12,13,15
	Managing Employee Information	1,2A,3,6,12,13,15
	Address Information	1,2A,3,12,13,15+addr
	Billing Agency Information	1,2A,3,6,8,13,15

Social Security Number	Date of Birth (mm/dd/yyyy)
Medicare ID (PTAN)	NPI (Type 1 - Individual)
Medical/Professional School		Year Graduated

Addiction Medicine	Hospitalist	Otolaryngology
Allergy/Immunology	Infectious Disease	Pain Management
Anesthesiology	Internal Medicine	Pathology
Cardiac Surgery	Interventional Cardiology	Pediatric Medicine
Cardiovascular Disease	Interventional Pain Mgmt	Peripheral Vascular Disease
Chiropractic	Interventional Radiology	Physical Medicine/Rehab
Colorectal Surgery	Maxillofacial Surgery	Plastic/Reconstructive Surgery
Critical Care (Intensivists)	Medical Genetics/Genomics	Podiatry
Dentist	Medical Oncology	Preventive Medicine
Dermatology	Nephrology	Psychiatry
Diagnostic Radiology	Neurology	Pulmonary Disease
Emergency Medicine	Neuropsychiatry	Radiation Oncology
Endocrinology	Neurosurgery	Rheumatology
Family Medicine	Nuclear Medicine	Sleep Medicine
Gastroenterology	Obstetrics/Gynecology	Sports Medicine
General Practice	Ophthalmology	Surgical Oncology
General Surgery	Optometry	Thoracic Surgery
Geriatric Medicine	Oral Surgery	Urology
Hematology/Oncology	Orthopedic Surgery	Vascular Surgery
Hospice/Palliative Care	Osteopathic Manipulative Med	Undefined:

Anesthesiology Assistant	Nurse Practitioner	Psychologist, Clinical
Certified Nurse Midwife	OT in Private Practice	Psychologist Billing Indep.
CRNA	PT in Private Practice	Qualified Audiologist
Clinical Nurse Specialist	Physician Assistant	Speech Language Pathologist
Clinical Social Worker	Mass Immunization Biller	Dietitian/Nutrition Prof.
Undefined:

a. Render services free from employer control?	Yes No
b. Treat your own patients?	Yes No
c. Right to bill directly and collect fees?	Yes No
d. Practice located in institution/facility?	Yes No

1. ONLY render services in patients' homes?	Yes No
2. Maintain private office space?	Yes No
3. Own, lease, or rent office space?	Yes No
4. Office used exclusively for private practice?	Yes No
5. Provide services outside office/homes?	Yes No