MediCare enrollMent aPPliCation

Clinics/group Practices

and Certain other Suppliers

CMS-855B

See Page 1 to deterMine if you are CoMPleting the CorreCt aPPliCation.

See Page 2 for inforMation on where to Mail thiS aPPliCation.

See Page 34 to find a liSt of the SuPPorting doCuMentation that MuSt Be

SuBMitted with thiS aPPliCation.

DEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0685

who Should SuBMit thiS aPPliCation

The following suppliers must complete this application to initiate the enrollment process:
Ambulance Service Supplier Independent Diagnostic Testing Facility (IDTF)
Ambulatory Surgical Center Mammography Center
Clinic/Group Practice Mass Immunization (Roster Biller Only)
Competitive Acquisition Program (CAP) Portable X-ray Supplier
Part B Drug Vendor Radiation Therapy Center
Independent Clinical Laboratory
If your supplier type is not listed above, contact your designated fee-for-service contractor before you
submit this application.

Complete and submit this application if you are an organization/group that plans to bill Medicare and you are:
• A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics,
independent laboratories, portable x-ray suppliers).
• A hospital or other medical practice or clinic that may bill for Medicare Part A services but will
also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other
entities that bill Medicare Part B.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another
fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic
territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have
added or changed a practice location). Changes must be reported in accordance with the timeframes
established in 42 C.F.R. § 424.520(b). (IDTF changes of information must be reported in accordance with
42 C.F.R. § 410.33.)

Billing nuMBer inforMation

The NPI is the standard unique health identifier for health care providers and is assigned by the National
Plan and Provider Enumeration System (NPPES). As a Medicare health supplier, you must obtain an
NPI prior to enrolling in Medicare or before submitting a change for your existing Medicare enrollment
information. Applying for an NPI is a process separate from Medicare enrollment. As a supplier, it is your
responsibility to determine if you have “subparts.” A subpart is a component of an organization (supplier)
that furnishes healthcare and is not itself a legal entity. If you do have subparts, you must determine if they
should obtain their own unique NPIs. Before you complete this enrollment application, you need to make
those determinations and obtain NPI(s) accordingly.
IMPortANt: For NPI purposes, sole proprietors and sole proprietorships are considered to be
“type 1” providers. organizations (e.g., corporations, partnerships) are treated as “type 2” entities.
When reporting the NPI of a sole proprietor on this application, therefore, the individual’s type 1
NPI should be reported; for organizations, the type 2 NPI should be furnished.
To obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov. For more information about subparts,
visit www.cms.hhs.gov/NationalProvIdentStand to view the “Medicare Expectations Subparts Paper.”
The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN)
or Medicare “legacy” number, is a generic term for any number other than the NPI that is used to identify
a Medicare supplier.

CMS-855B (02/08) (EF 07/09) 1

 inStruCtionS for CoMPleting and SuBMitting thiS aPPliCation
• Type or print all information so that it is legible. Do not use pencil.

• Report additional information within a section by copying and completing that section for each
additional entry.

• Attach all required supporting documentation.

• Keep a copy of your completed Medicare enrollment package for your records.

• Send the completed application with original signatures and all required documentation to your
designated Medicare fee-for-service contractor.

aVoid delayS in your enrollMent

To avoid delays in the enrollment process, you should:

• Complete all required sections.
• Ensure that the legal business name shown in Section 2 matches the name on the tax documents.
• Ensure that the correspondence address shown in Section 2 is the supplier’s address.
• Enter your NPI in the applicable sections.
• Enter all applicable dates.
• Ensure that the correct person signs the application.
• Send your application and all supporting documentation to the designated fee-for-service contractor.

additional inforMation

For additional information regarding the Medicare enrollment process, visit www.cms.hhs.gov/
MedicareProviderSupEnroll.

The fee-for-service contractor may request, at any time during the enrollment process, documentation to
support and validate information reported on the application. You are responsible for providing this
documentation in a timely manner.

The information you provide on this application will not be shared. It is considered to be protected under 5 U.S.C.
Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the
Privacy Act Statement.

Mail your aPPliCation

The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative contractor)
that services your State is responsible for processing your enrollment application. To locate the mailing
address for your fee-for-service contractor, go to www.cms.hhs.gov/MedicareProviderSupEnroll.

CMS-855B (02/08) (EF 07/09) 2

SeCtion 1: BaSiC inforMation

new enrolleeS and thoSe with a new tax id nuMBer

If you are:
• Enrolling in the Medicare program for the first time with this Medicare fee-for-service contractor under
this tax identification number.
• Already enrolled with a Medicare fee-for-service contractor but are establishing a practice location in
another fee-for-service contractor’s jurisdiction.
• Enrolled with a Medicare fee-for-service contractor but have a new tax identification number. If you
are reporting a change to your tax identification number, you must complete a new application.
• A hospital or an individual hospital department that is enrolling with a fee-for-service contractor to bill
for Part B services.

enrolled MediCare SuPPlierS

The following actions apply to Medicare suppliers already enrolled in the program:

reactivation
To reactivate your Medicare billing privileges, submit this enrollment application. In addition, prior to
being reactivated, you must be able to submit a valid claim and meet all current requirements for your
supplier type before reactivation may occur.

Voluntary termination
A supplier should voluntarily terminate its Medicare enrollment when it:
• Will no longer be rendering services to Medicare patients, or
• Is planning to cease (or has ceased) operations.

Change of ownership
If a hospital, ambulatory surgical center, or portable X-ray supplier is undergoing a change of ownership
(CHOW) in accordance with the principles outlined in 42 C.F.R. 489.18, the entity must submit a new
application for the new ownership.

Change of information
A change of information should be submitted if you are changing, adding or deleting information under your
current tax identification number.

Changes in your existing enrollment data must be reported to the fee-for-service contractor in accordance
with 42 C.F.R. § 424.516 (Physician and Non Physician Practitioner Organizations). (IDTF changes of
information must comply with the provisions found at 42 C.F.R. § 410.33.)

If you are already enrolled in Medicare and are not receiving Medicare payments via EFT, any
change to your enrollment information will require you to submit a CMS-588 form. All future
payments will then be made via EFT.

revalidation
CMS may require you to submit or update your enrollment information. The fee-for-service contractor will
notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation
application until you have been contacted by the fee-for-service contractor.

CMS-855B (02/08) (EF 07/09) 3

SeCtion 1: BaSiC inforMation
all aPPliCantS MuSt CoMPlete thiS SeCtion (See instructions for details.)

a. Check one box and complete the required sections.

reaSon for aPPliCation Billing nuMBer inforMation reQuired SeCtionS
Complete all sections
Enter your Medicare
Identification Number (if Ambulance suppliers must
You are a new enrollee in Medicare issued) and the NPI you would complete Attachment 1
like to link to this number in
Section 4. IDtF suppliers must
complete Attachment 2
Complete all sections
Enter your Medicare
You are enrolling in another Identification Number (if Ambulance suppliers must
fee-for-service contractor’s issued) and the NPI you would complete Attachment 1
jurisdiction like to link to this number in
Section 4. IDtF suppliers must
complete Attachment 2
Complete all sections
Enter your Medicare
Identification Number (if Ambulance suppliers must
You are reactivating your issued) and the NPI you would complete Attachment 1
Medicare enrollment like to link to this number in
Section 4. IDtF suppliers must
complete Attachment 2
Sections 1, 2B1, 13, and either
Effective Date of Termination
15 or 16
You are voluntarily terminating
Medicare Identification
your Medicare enrollment. (This is If you are terminating an
Number to Terminate (if issued):
not the same as “opting out” of the employment arrangement
program) with a physician assistant,
NPI number (if issued):
complete Sections 1A, 2G, 13,
and either 15 or 16

Medicare Identification
You are changing your Number (if issued):
Go to Section 1B
Medicare information
NPI:

Complete all sections

Enter your Medicare
Identification Number (if Ambulance suppliers must
You are revalidating your
issued) and the NPI you would complete Attachment 1
Medicare enrollment
like to link to this number in
Section 4. IDtF suppliers must
complete Attachment 2

CMS-855B (02/08) (EF 07/09) 4

SeCtion 1: BaSiC inforMation (Continued)

B. Check all that apply and complete the required sections:

reQuired SeCtionS

1, 2 (complete only those sections that are changing),

3, 13, and either 15 (if you are an authorized official)
Identifying Information or 16 (if you are a delegated official), and 6 for the
signer if that authorized or delegated official has not
been established for this supplier
1, 2B1, 3, 13, and either 15 (if you are an authorized
official) or 16 (if you are a delegated official), and
Final Adverse Actions/Convictions
6 for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 4 (complete only those sections that are
Practice Location Information, Payment changing), 13, and either 15 (if you are an authorized
Address & Medical Record Storage official) or 16 (if you are a delegated official), and
Information 6 for the signer if that authorized or delegated official
has not been established for this supplier
Change of Ownership (Hospitals, Portable
Complete all sections and
X-Ray Suppliers & Ambulatory Surgical
provide a copy of the sales agreement
Centers Only)

1, 2B1, 3, 5, 13, and either 15 (if you are an authorized

Ownership Interest and/or Managing official) or 16 (if you are a delegated official), and 6
Control Information (Organizations) for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 6, 13, and either 15 (if you are an authorized
Ownership Interest and/or Managing Control official) or 16 (if you are a delegated official), and 6
Information (Individuals) for the signer if that authorized or delegated official
has not been established for this supplier
1, 2B1, 3, 8 (complete only those sections that are
changing), 13, and either 15 (if you are an authorized
Billing Agency Information official) or 16 (if you are a delegated official), and 6
for the signer if that authorized or delegated official
has not been established for this supplier

1, 2B1, 3, 13, and either 15 (if you are an authorized

official) or 16 (if you are a delegated official), and 6
Authorized Official(s)
for the signer if that authorized or delegated official
has not been established for this supplier

Delegated Official(s) (Optional) 1, 2B1, 3, 13, 15 and 16

CMS-855B (02/08) (EF 07/09) 5

SeCtion 1: BaSiC inforMation (Continued)

attaChMent 1—aMBulanCe SerViCe SuPPlierS (only) reQuired SeCtionS

1, 2B1, 3, 13, and 15 if you are the

authorized official or 16 if you are the
Geographic Area
delegated official
Attachment 1(A)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
State License Information
delegated official
Attachment 1(B)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Paramedic Intercept Services Information
delegated official
Attachment 1(C)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Vehicle Information
delegated official
Attachment 1(D)
attaChMent 2—indePendent diagnoStiC teSting faCilitieS (only) reQuired SeCtionS

1, 2B1, 3, 13, and 15 if you are the

authorized official or 16 if you are the
CPT-4 and HCPCS Codes
delegated official
Attachment 2(B)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Interpreting Physician Information
delegated official
Attachment 2(C)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Personnel (Technicians) Who Perform Tests
delegated official
Attachment 2(D)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Supervising Physician(s)
delegated official
Attachment 2(E)
1, 2B1, 3, 13, and 15 if you are the
authorized official or 16 if you are the
Liability Insurance Information
delegated official
Attachment 2(F)

CMS-855B (02/08) (EF 07/09) 6

SeCtion 2: identifying inforMation

a. tyPe of SuPPlier
Check the appropriate box to identify the type of supplier you are enrolling as with Medicare. if you are more than
one type of supplier, submit a separate application for each type. if you change the type of service that you provide
(i.e., become a different supplier type), submit a new application.

Your organization must meet all Federal and State requirements for the type of supplier checked below.
tyPe of SuPPlier: (check one only)
Ambulance Service Supplier Independent Clinical Laboratory
Ambulatory Surgical Center
Independent Diagnostic Testing Facility
Clinic/Group Practice
Mammography Center
Single Specialty Clinic _______________ Mass Immunization (Roster Biller Only)
Provide Speciality
Multi-Specialty Clinic Pharmacy
Hospital Department(s) Portable X-ray Supplier
Physical/Occupational Therapy Group Radiation Therapy Center
in Private Practice Other (Specify):_______________________
Competitive Acquisition Program
(CAP) Part B Drug Vendor

B. SuPPlier identifiCation inforMation

1. BuSineSS inforMation

Legal Business Name (not the “Doing Business As” name) as reported to the Internal Revenue Service

Tax Identification Number

Other Name Type of Other Name

Former Legal Business Name
Doing Business As Name
Other (Specify): ________________________________
Identify the type of organizational structure of this provider (Check one)
Corporation Limited Liability Company Partnership Sole Proprietor Other (Specify):_____________________
Incorporation Date (mm/dd/yyyy) (if applicable) State Where Incorporated (if applicable)

CMS-855B (02/08) (EF 07/09) 7

SeCtion 2: identifying inforMation (Continued)

2. State liCenSe inforMation/CertifiCation inforMation

Provide the following information if the supplier has a State license/certification to operate as the supplier
type for which you are enrolling.

State license information

License Not Applicable
License Number State Where Issued

Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy)

Certification information
Certification Not Applicable
Certification Number State Where Issued

Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy)

3. CorreSPondenCe addreSS
Provide contact information for the entity or person listed in Question 1 of this section. Once enrolled, the
information provided below will be used by the fee-for-service contractor if it needs to contact you directly.
This address cannot be a billing agency’s address.
Mailing Address Line 1 (Street Name and Number)

Mailing Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

Telephone Number Fax Number (if applicable) E-mail Address (if applicable)

C. hoSPitalS only
This section should only be completed by hospitals that are currently enrolled or enrolling with a fee-for­
service contractor (the Part A Medicare contractor), and will be billing a fee-for-service contractor for
Medicare Part B services, as follows:
• Hospitals that need departmental billing numbers to bill for Part B practitioner services.
• Hospitals requiring a Part B billing number to provide pathology services.
• Hospitals requiring a Medicare Part B billing number to provide purchased tests to other
Medicare Part B billers.
• If the hospital requires more than one departmental Part B billing number, list each department
needing a number.

If your organization is not a hospital, and believes it will need a Part B billing number, contact the local
fee-for-service contractor to determine if this form should be submitted.

CMS-855B (02/08) (EF 07/09) 8

SECTION 2: IDENTIFYING INFORMATION (Continued)

C. HOSPITALS ONLY (Continued)

NOTE: If your hospital is enrolling a clinic that is not provider-based, do not complete this section.
Check “Clinic/Group Practice” in Section 2A and complete this entire application for the clinic.

1. Are you going to:

bill for the entire hospital with one billing number? (If yes, continue to Section 2D.)
separately bill for each hospital department? (If yes, answer Question 2.)
2. List the hospital departments for which you plan to bill separately:
Department Medicare Identification Number NPI
______________________ ___________________________ _________________________
______________________ ___________________________ _________________________
______________________ ___________________________ _________________________
______________________ ___________________________ _________________________
D. COMMENTS/SPECIAL CIRCUMSTANCES
Explain any unique circumstances concerning your practice location, the method by which
you render health care services, etc.

E. PHYSICAL THERAPY (PT) AND OCCUPATIONAL THERAPY (OT) GROUPS ONLY

1) Are all of the group’s PT/OT services rendered in patients’ homes or

in the group’s private office space? YES NO
2) Does this group maintain private office space? YES NO
3) Does this group own, lease, or rent its private office space? YES NO
4) Is this private office space used exclusively for the group’s private practice? YES NO
5) Does this group provide PT/OT services outside of its office and/or patients’ homes? YES NO
If you responded YES to any of the questions 2–5 above, submit a copy of the lease agreement that gives the
group exclusive use of the facilities for PT/OT services.

F. ACCREDITATION FOR AMBULATORY SURGICAL CENTERS (ASCs) ONLY

Is this ASC accredited? YES NO
If YES, complete the following:
Date of Accreditation (mm/dd/yyyy) _____________________________________________________
Name of Accrediting Body_____________________________________________________________

CMS-855B (02/08) (EF 07/09) 9

SeCtion 2: identifying inforMation (Continued)

g. terMination of PhySiCian aSSiStantS (only)

Complete this section to delete employed physician assistants from your group or clinic.
effective date Physician assistant’s Physician assistant’s Physician assistant’s
of departure name Medicare nPi
identification number

____________________ ____________________ ____________________ ____________________

____________________ ____________________ ____________________ ____________________
____________________ ____________________ ____________________ ____________________
____________________ ____________________ ____________________ ____________________
____________________ ____________________ ____________________ ____________________
____________________ ____________________ ____________________ ____________________
____________________ ____________________ ____________________ ____________________
____________________ ____________________ ____________________ ____________________

CMS-855B (02/08) (EF 07/09) 10

SeCtion 3: final adVerSe aCtionS/ConViCtionS

This section captures information on final adverse actions, such as convictions, exclusions, revocations,
and suspensions. All applicable final legal actions must be reported, regardless of whether any records
were expunged or any appeals are pending.
final adVerSe aCtionS that MuSt Be rePorted
Convictions
1. The provider, supplier, or any owner of the provider or supplier was, within the last 10 years preceding
enrollment or revalidation of enrollment, convicted of a Federal or State felony offense that
CMS has determined to be detrimental to the best interests of the program and its beneficiaries.
Offenses include:
Felony crimes against persons and other similar crimes for which the individual was convicted,
including guilty pleas and adjudicated pre-trial diversions; financial crimes, such as extortion,
embezzlement, income tax evasion, insurance fraud and other similar crimes for which the
individual was convicted, including guilty pleas and adjudicated pre-trial diversions; any felony
that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit
that results in a conviction of criminal neglect or misconduct); and any felonies that would result
in a mandatory exclusion under Section 1128(a) of the Act.
2. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or
service under Medicare or a State health care program, or (b) the abuse or neglect of a patient in
connection with the delivery of a health care item or service.
3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement,
breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health
care item or service.
4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with
or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section
1001.101 or 1001.201.
5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful
manufacture, distribution, prescription, or dispensing of a controlled substance.

exclusions, revocations, or Suspensions

1. Any revocation or suspension of a license to provide health care by any State licensing authority.
This includes the surrender of such a license while a formal disciplinary proceeding was pending
before a State licensing authority.
2. Any revocation or suspension of accreditation.
3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or
State health care program, or any debarment from participation in any Federal Executive Branch
procurement or non-procurement program.
4. Any current Medicare payment suspension under any Medicare billing number.
5. Any Medicare revocation of any Medicare billing number.

CMS-855B (02/08) (EF 07/09) 11

SeCtion 3: final adVerSe aCtionS/ConViCtionS (Continued)

final adVerSe aCtion hiStory

1. Has your organization, under any current or former name or business identity, ever had a final
adverse action listed on page 11 of this application imposed against it?

YES–Continue Below NO–Skip to Section 4

2. If yes, report each final adverse action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse action documentation and resolution.
final adverse action date taken By resolution

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

CMS-855B (02/08) (EF 07/09) 12

SeCtion 4: PraCtiCe loCation inforMation

inStruCtionS
This section captures information about the physical location(s) where you currently provide health care
services. If you operate a mobile facility or portable unit, provide the address for the “Base of Operations,”
as well as vehicle information and the geographic area serviced by these facilities or units.

Only report those practice locations within the jurisdiction of the Medicare fee-for-service contractor to
which you will submit this application. If you have practice locations in another Medicare fee-for-service
contractor’s jurisdiction, complete a separate enrollment application (CMS-855B) for those practice locations
and submit it to the Medicare fee-for-service contractor that has jurisdiction over those locations.

Provide the specific street address as recorded by the United States Postal Service. Do not provide a P.O.
Box. If you provide services in a hospital and/or other health care facility for which you bill Medicare
directly for the services rendered at that facility, provide the name and address of the hospital or facility.

MoBile faCility and/or PortaBle unit

A “mobile facility” is generally a mobile home, trailer, or other large vehicle that has been converted,
equipped, and licensed to render health care services. These vehicles usually travel to local shopping centers
or community centers to see and treat patients inside the vehicle.

A “portable unit” is when the supplier transports medical equipment to a fixed location (e.g., physician’s
office, nursing home) to render services to the patient.

The most common types of mobile facilities/portable units are mobile IDTFs, portable X-ray suppliers,
portable mammography, and mobile clinics. Physicians and non-physician practitioners (e.g., nurse
practitioners, physician assistants) who perform services at multiple locations (e.g., house calls, assisted
living facilities) are not considered to be mobile facilities/portable units.

CMS-855B (02/08) (EF 07/09) 13

SeCtion 4: PraCtiCe loCation inforMation (Continued)

a. PraCtiCe loCation inforMation

If you see patients in more than one practice location, copy and complete Section 4A for each location.
To ensure that CMS establishes the correct association between your Medicare legacy number and
your NPI, providers and suppliers must list a Medicare legacy number—NPI combination for each
practice location. If you have multiple NPIs associated with both a single legacy number and a single
practice location, please list below all NPIs and associated legacy numbers for that practice location.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

if you are enrolling for the first time, or if you are adding a new practice location,

the date you provide should be the date you saw your first Medicare patient at this location.

Practice Location Name (“Doing Business As” name if different from Legal Business Name)

Practice Location Address Line 1 (Street Name and Number)

Practice Location Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code +4

Telephone Number Fax Number (if applicable) E-mail Address (if applicable)

Date you first started rendering services to Medicare patients at this practice location (mm/dd/yyyy)

Medicare Identification Number (if issued) National Provider Identifier

Medicare Identification Number (if issued) National Provider Identifier

Medicare Identification Number (if issued) National Provider Identifier

Medicare Identification Number (if issued) National Provider Identifier

Medicare Identification Number (if issued) National Provider Identifier

Is this practice location a (check one):

Group practice office/clinic Retirement/assisted living community
Hospital Other health care facility (specify):____________________
CLIA Number for this location (if applicable)

Attach a copy of the most current CLIA certifications for each of the practice locations reported on this application.

FDA/Radiology (Mammography) Certification Number(s) for this location (if applicable)

Attach a copy of the most current FDA certifications for each of the practice locations reported on this application.

CMS-855B (02/08) (EF 07/09) 14

SeCtion 4: PraCtiCe loCation inforMation (Continued)

B. where do you want reMittanCe notiCeS or SPeCial PayMentS Sent?

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Medicare will issue payments via electronic funds transfer (EFt). Since payments will be made by
EFT, the “Special Payments” address should indicate where all other payment information (e.g., remittance
notices, special payments) should be sent.
“Special Payments” address is the same as the practice location (only one address is listed in
Section 4A). Skip to Section 4C.
“Special Payments” address is different than that listed in Section 4A, or multiple locations are
listed. Provide address below.
“Special Payments” Address Line 1 (PO Box or Street Name and Number)

“Special Payments” Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

C. where do you KeeP PatientS’ MediCal reCordS?

If you store patients’ medical records (current and/or former patients) at a location other than the location in
Section 4A or 4E, complete this section with the address of the storage location.

Post Office boxes and drop boxes are not acceptable as physical addresses where patients’ records are
maintained. For IDTFs and mobile facilities/portable units, the patients’ medical records must be under the
supplier’s control. The records must be the supplier’s records, not the records of another supplier. If this
section is not completed, you are indicating that all records are stored at the practice locations reported in
Section 4A or 4E.

CMS-855B (02/08) (EF 07/09) 15

SeCtion 4: PraCtiCe loCation inforMation (Continued)

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

first Medical record Storage facility (for current and former patients)
Storage Facility Address Line 1 (Street Name and Number)

Storage Facility Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

Second Medical record Storage facility (for current and former patients)

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Storage Facility Address Line 1 (Street Name and Number)

Storage Facility Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

CMS-855B (02/08) (EF 07/09) 16

SeCtion 4: PraCtiCe loCation inforMation (Continued)

d. rendering SerViCeS in PatientS’ hoMeS

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Furnish the city/town, State and ZIP code for all locations where health care services are rendered in patients’
homes. If you provide health care services in more than one State and those States are serviced by different
Medicare fee-for-service contractors, complete a separate CMS-855B enrollment application for each
Medicare fee-for-service contractor’s jurisdiction.

If you are adding or deleting an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.
Entire State of __________________________
If you are providing services in selected cities/towns, furnish the locations below. Only list ZIP codes if you
are not servicing the entire city/town.
City/town State ZiP Code
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________

CMS-855B (02/08) (EF 07/09) 17

SeCtion 4: PraCtiCe loCation inforMation (Continued)

e. BaSe of oPerationS addreSS for MoBile or PortaBle SuPPlierS

(loCation of BuSineSS offiCe or diSPatCher/SCheduler)
The base of operations is the location from where personnel are dispatched, where mobile/portable equipment
is stored, and when applicable, where vehicles are parked when not in use.

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Check here and skip to Section 4F if the “Base of operations” address is the same as the “Practice
Location” listed in Section 4A.
Street Address Line 1 (Street Name and Number)

Street Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

Telephone Number Fax Number (if applicable) E-mail Address (if applicable)

f. VehiCle inforMation
If the mobile health care services are rendered inside a vehicle, such as a mobile home or trailer, furnish the
following vehicle information. Do not provide information about vehicles that are used only to transport medical
equipment (e.g., when the equipment is transported in a van but is used in a fixed setting, such as a doctor’s
office) or ambulance vehicles. If more than two vehicles are used, copy and complete this section as needed.

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one for eaCh VehiCle Type of Vehicle (van, mobile home, trailer, etc.) Vehicle Identification Number

CHANGE ADD DELETE

Effective Date:

CHANGE ADD DELETE

Effective Date:

For each vehicle, submit a copy of all health care related permits/licenses/registrations.

CMS-855B (02/08) (EF 07/09) 18

SeCtion 4: PraCtiCe loCation inforMation (Continued)

g. geograPhiC loCation for MoBile or PortaBle SuPPlierS

where the BaSe of oPerationS and/or VehiCle renderS SerViCeS
Provide the city/town, State, and ZIP Code for all locations where mobile and/or portable services
are rendered.

note: If you provide mobile or portable health care services in more than one State and those States are
serviced by different Medicare fee-for-service contractors, complete a separate enrollment application
(CMS-855B) for each Medicare fee-for-service contractor’s jurisdiction.

initial rePorting and/or additionS

If you are reporting or adding an entire State, it is not necessary to report each city/town. Simply check the
box below and specify the State.

Entire State of __________________________

If services are provided in selected cities/towns, provide the locations below. Only list ZIP codes if you are

not servicing the entire city/town.

City/town State ZiP Code

___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________

deletionS
If you are deleting an entire State, it is not necessary to report each city/town. Simply check the box below
and specify the State.

Entire State of __________________________

If services you are deleting are furnished in selected cities/towns, provide the locations below. Only list
ZIP codes if you are not servicing the entire city/town.

City/town State ZiP Code

___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________

CMS-855B (02/08) (EF 07/09) 19

SeCtion 5: ownerShiP intereSt and/or Managing
Control inforMation (organiZationS)
note: only rePort organiZationS in thiS SeCtion. indiVidualS MuSt Be rePorted in SeCtion 6.

Complete this section with information about all organizations that have 5 percent or more (direct or
indirect) ownership interest of, any partnership interest in, and/or managing control of, the supplier
identified in Section 2, as well as information on any adverse legal actions that have been imposed against
that organization. For examples of organizations that should be reported here, visit our Web site: www.cms.
hhs.gov/MedicareProviderSupEnroll. If there is more than one organization that should be reported, copy and
complete this section for each.

Managing Control (organiZationS)

Any organization that exercises operational or managerial control over the supplier, or conducts the day-to­
day operations of the supplier, is a managing organization and must be reported. The organization need not
have an ownership interest in the supplier in order to qualify as a managing organization. For instance, it
could be a management services organization under contract with the supplier to furnish management
services for the business.

SPeCial tyPeS of organiZationS

governmental/tribal organizations: If a Federal, State, county, city or other level of government, or

an Indian tribe, will be legally and financially responsible for Medicare payments received (including any
potential overpayments), the name of that government or Indian tribe should be reported as an owner. The
supplier must submit a letter on the letterhead of the responsible government (e.g., government agency)
or tribal organization that attests that the government or tribal organization will be legally and financially
responsible in the event that there is any outstanding debt owed to CMS. This letter must be signed by an
appointed or elected official of the government or tribal organization who has the authority to legally and
financially bind the government or tribal organization to the laws, regulations, and program instructions of
the Medicare program.

non-Profit, Charitable and religious organizations: Many non-profit organizations are charitable
or religious in nature, and are operated and/or managed by a board of trustees or other governing body.
The actual name of the board of trustees or other governing body should be reported in this section. While
the organization should be listed in Section 5, individual board members should be listed in Section 6. Each
non-profit organization should submit a copy of a 501(c)(3) document verifying its non-profit status.

CMS-855B (02/08) (EF 07/09) 20

SeCtion 5: ownerShiP intereSt and/or Managing
Control inforMation (organiZationS) (Continued)

All organizations that have any of the following must be reported in Section 5:
• 5 percent or more ownership of the supplier,
• Managing control of the supplier, or
• A partnership interest in the supplier, regardless of the percentage of ownership the partner has.
Owning/Managing organizations are generally one of the following types:
• Corporations (including non-profit corporations)
• Partnerships and Limited Partnerships (as indicated above)
• Limited Liability Companies
• Charitable and/or Religious organizations
• Governmental and/or Tribal organizations

a. organiZation with ownerShiP intereSt and/or Managing

Control identifiCation inforMation

Not Applicable

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Check all that apply:

5 Percent or More Ownership Interest Partner Managing Control
Legal Business Name as Reported to the Internal Revenue Service

“Doing Business As” Name (if applicable)

Address Line 1 (Street Name and Number)

Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4 NPI (if issued)

Tax Identification Number (Required) Medicare Identification Number(s) (if issued)

CMS-855B (02/08) (EF 07/09) 21

SeCtion 5: ownerShiP intereSt and/or Managing
Control inforMation (organiZationS) (Continued)

B. final adVerSe hiStory

If reporting a change to existing information, check “Change,” provide the effective date of the change,
and complete the appropriate fields in this section.
Change Effective Date:__________________________
1. Has this organization in Section 5A, under any current or former name or business identity, ever had a
final adverse action listed on page 11 of this application imposed against it?

YES – Continue Below NO – Skip to Section 6

2. If YES, report each final adverse action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution.

Attach a copy of the final adverse action documentation(s) and resolution(s).

final adverse action date taken By resolution

___________________ ___________________ ___________________ _________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

_______________________ ______________________ ______________________ _____________________

CMS-855B (02/08) (EF 07/09) 22

SeCtion 6: ownerShiP intereSt and/or Managing
Control inforMation (indiVidualS)
note: Only Individuals should be reported in Section 6. Organizations must be reported in Section 5. For
more information on “direct” and “indirect” owners, go to www.cms.hhs.gov/MedicareProviderSupEnroll.
the supplier MuSt have at least one owner and/or managing employee.
The following individuals must be reported in Section 6A:
• All persons who have a 5 percent or greater direct or indirect ownership interest in the supplier;
• If (and only if) the supplier is a corporation (whether for-profit or non-profit), all officers and

directors of the supplier;

• All managing employees of the supplier;

• All individuals with a partnership interest in the supplier, regardless of the percentage of

ownership the partner has; and

• Authorized and delegated officials.

example: A supplier is 100 percent owned by Company C, which itself is 100 percent owned by
Individual D. Assume that Company C is reported in Section 5A as an owner of the supplier. Assume
further that Individual D, as an indirect owner of the supplier, is reported in Section 6A1. Based on this
example, the supplier would check the “5 percent or Greater Direct/Indirect Owner” box in Section 6A2.
note: All partners within a partnership must be reported on this application. This applies to both “General”
and “Limited” partnerships. For instance, if a limited partnership has several limited partners and each of
them only has a 1 percent interest in the supplier, each limited partner must be reported on this application,
even though each owns less than 5 percent. The 5 percent threshold primarily applies to corporations and
other organizations that are not partnerships.

non-Profit, Charitable or religious organizations: If you are a non-profit charitable or religious

organization that has no organizational or individual owners (only board members, directors or managers),
you should submit with your application a 501(c)(3) document verifying non-profit status.

For purposes of this application, the terms “officer,” “director,” and “managing employee” are defined as follows:
officer is any person whose position is listed as being that of an officer in the supplier’s “articles of
incorporation” or “corporate bylaws,” or anyone who is appointed by the board of directors as an officer
in accordance with the supplier’s corporate bylaws.

director is a member of the supplier’s “board of directors.” It does not necessarily include a person
who may have the word “director” in his/her job title (e.g., departmental director, director of operations).
Moreover, where a supplier has a governing body that does not use the term “board of directors,” the
members of that governing body will still be considered “directors.” Thus, if the supplier has a governing
body titled “board of trustees” (as opposed to “board of directors”), the individual trustees are considered
“directors” for Medicare enrollment purposes.
Managing employee means a general manager, business manager, administrator, director, or other
individual who exercises operational or managerial control over, or who directly or indirectly conducts, the
day-to-day operations of the supplier, either under contract or through some other arrangement, regardless
of whether the individual is a W-2 employee of the supplier.
note: If a governmental or tribal organization will be legally and financially responsible for Medicare
payments received (per the instructions for Governmental/Tribal Organizations in Section 5), the supplier
is only required to report its managing employees in Section 6. Owners, partners, officers, and directors do
not need to be reported, except those who are listed as authorized or delegated officials on this application.

CMS-855B (02/08) (EF 07/09) 23

SeCtion 6: ownerShiP intereSt and/or Managing
Control inforMation (indiVidualS) (Continued)
Any information on final adverse actions that have been imposed against the individuals reported in
this section must be furnished. If there is more than one individual, copy and complete this section for
each individual. Owners, Authorized Officials and/or Delegated Officials must complete this section.

a. indiVidualS with ownerShiP intereSt and/or Managing Control —

identifiCation inforMation
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section. The name, date of birth, and social security number of
each person listed in this Section must coincide with the individual’s information as listed with the Social
Security Administration.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

1. First Name Middle Initial Last Name Jr., Sr., etc.

Social Security Number (Required) Date of Birth (mm/dd/yyyy) Medicare Identification Number (if issued) NPI (if issued)

2. What is the above individual’s relationship with the supplier in Section 2B1? (Check all that apply.)
5 Percent or Greater Direct/Indirect Owner Director/Officer

Partner
Contracted Managing Employee
Managing Employee (W-2) Other _______________________________

B. final adVerSe hiStory

Complete this section for the individual reported in Section 6A above. If reporting a change to existing
information, check “change,” provide the effective date of the change and complete the appropriate fields
in this section.
Change Effective Date:__________________________

1. Has this individual in Section 6A, under any current or former name or business identity, ever had a
final adverse action listed on page 11 of this application imposed against him/her?

YES–Continue Below NO–Skip to Section 8

2. If YES, report each final adverse action, when it occurred, the Federal or State agency or the court/
administrative body that imposed the action, and the resolution, if any.
Attach a copy of the final adverse action documentation and resolution.
final adverse action date taken By resolution
___________________ ___________________ ___________________ _________________
_______________________ ______________________ ______________________ _____________________
_______________________ ______________________ ______________________ _____________________
_______________________ ______________________ ______________________ _____________________
_______________________ ______________________ ______________________ _____________________
_______________________ ______________________ ______________________ _____________________
CMS-855B (02/08) (EF 07/09) 24
SeCtion 7: for future uSe (this Section not applicable)

SeCtion 8: Billing agenCy inforMation

A billing agency is a company or individual that you contract with to prepare and submit your claims. If
you use a billing agency, you are responsible for the claims submitted on your behalf.

Check here if this section does not apply and skip to Section 13.

Billing agenCy naMe and addreSS

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Legal Business/Individual Name as Reported to the Social Security Administration Tax Identification/Social Security Number (required)
or the Internal Revenue Service
“Doing Business As” Name (if applicable)

Billing Agency Street Address Line 1 (Street Name and Number)

Billing Agency Street Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

Telephone Number Fax Number (if applicable) E-mail Address (if applicable)

SeCtion 9: for future uSe (this Section not applicable)

SeCtion 10: for future uSe (this Section not applicable)

SeCtion 11: for future uSe (this Section not applicable)

SeCtion 12: for future uSe (this Section not applicable)

CMS-855B (02/08) (EF 07/09) 25

SeCtion 13: ContaCt PerSon

If questions arise during the processing of this application, the fee-for-service contractor will contact the
individual shown below. If the contact person is either an authorized or delegated official, check the
appropriate box below.
Contact an Authorized Official listed in Section 15.
Contact a Delegated Official listed in Section 16.

First Name Middle Initial Last Name

Telephone Number Fax Number (if applicable)

Address Line 1 (Street Name and Number)

Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

E-mail Address

CMS-855B (02/08) (EF 07/09) 26

SeCtion 14: PenaltieS for falSifying inforMation

this section explains the penalties for deliberately falsifying information in this application
to gain or maintain enrollment in the Medicare program.

1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the
jurisdiction of any department or agency of the United States, knowingly and willfully falsifies,
conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or
fraudulent statements or representations, or makes any false writing or document knowing the same to
contain any false, fictitious or fraudulent statement or entry.

Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years.
Offenders that are organizations are subject to fines of up to $500,000 (18 U.S.C. § 3571). Section
3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than
the amount specifically authorized by the sentencing statute.

2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual
who, “knowingly and willfully,” makes or causes to be made any false statement or representation of
a material fact in any application for any benefit or payment under a Federal health care program.

The offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.

3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who:
a) knowingly presents, or causes to be presented, to an officer or any employee of the United
States Government a false or fraudulent claim for payment or approval;
b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false
or fraudulent claim paid or approved by the Government; or
c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.

The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of
damages sustained by the Government.

4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including
an organization, agency or other entity) that knowingly presents or causes to be presented to an
officer, employee, or agent of the United States, or of any department or agency thereof, or of any
State agency…a claim…that the Secretary determines is for a medical or other item or service that
the person knows or should know:
a) was not provided as claimed; and/or
b) the claim is false or fraudulent.

This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an
assessment of up to three times the amount claimed, and exclusion from participation in the Medicare
program and State health care programs.

5. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health
care benefit program who knowingly and willfully falsifies, conceals or covers up by any trick,
scheme, or device a material fact; or makes any materially false, fictitious, or fraudulent statements
or representations, or makes or uses any materially false fictitious, or fraudulent statement or entry, in
connection with the delivery of or payment for health care benefits, items or services. The individual
shall be fined or imprisoned up to 5 years or both.

CMS-855B (02/08) (EF 07/09) 27

SeCtion 14: PenaltieS for falSifying inforMation (Continued)

6. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute,
or attempt, to executive a scheme or artifice to defraud any health care benefit program, or to obtain,
by means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by or under the control of any, health care benefit program in connection with the delivery of
or payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up
to 10 years or both. If the violation results in serious bodily injury, an individual will be fined or
imprisoned up to 20 years, or both. If the violation results in death, the individual shall be fined or
imprisoned for any term of years or for life, or both.

7. The government may assert common law claims such as “common law fraud,” “money paid by mistake,”
and “unjust enrichment.”

Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the
unjust profit.

CMS-855B (02/08) (EF 07/09) 28

SeCtion 15: CertifiCation StateMent

An authoriZed offiCial means an appointed official (for example, chief executive officer, chief
financial officer, general partner, chairman of the board, or direct owner) to whom the organization has
granted the legal authority to enroll it in the Medicare program, to make changes or updates to the
organization’s status in the Medicare program, and to commit the organization to fully abide by the
statutes, regulations, and program instructions of the Medicare program.

A delegated offiCial means an individual who is delegated by an authorized official the authority to
report changes and updates to the supplier’s enrollment record. A delegated official must be an individual
with an “ownership or control interest” in (as that term is defined in Section 1124(a)(3) of the Social
Security Act), or be a W-2 managing employee of, the supplier.

Delegated officials may not delegate their authority to any other individual. Only an authorized official
may delegate the authority to make changes and/or updates to the supplier’s Medicare status. Even when
delegated officials are reported in this application, an authorized official retains the authority to make
any such changes and/or updates by providing his or her printed name, signature, and date of signature as
required in Section 15B.

note: Authorized officials and delegated officials must be reported in Section 6, either on this application
or on a previous application to this same Medicare fee-for-service contractor. If this is the first time an
authorized and/or delegated official has been reported on the CMS-855B, you must complete Section
6 for that individual.

By his/her signature(s), an authorized official binds the supplier to all of the requirements listed in the
Certification Statement and acknowledges that the supplier may be denied entry to or revoked from the
Medicare program if any requirements are not met. All signatures must be original and in ink. Faxed,
photocopied, or stamped signatures will not be accepted.

Only an authorized official has the authority to sign (1) the initial enrollment application on behalf of the
supplier or (2) the enrollment application that must be submitted as part of the periodic revalidation process. A
delegated official does not have this authority.

By signing this application, an authorized official agrees to immediately notify the Medicare fee-for-service
contractor if any information furnished on the application is not true, correct, or complete. In addition,
an authorized official, by his/her signature, agrees to notify the Medicare fee-for-service contractor of
any future changes to the information contained in this form, after the supplier is enrolled in Medicare, in
accordance with the timeframes established in 42 C.F.R. 424.520(b). (IDTF changes of information must
be reported in accordance with 42 C.F.R. 410.33.)

The supplier can have as many authorized officials as it wants. If the supplier has more than two authorized
officials, it should copy and complete this section as needed.

eaCh authoriZed and delegated offiCial MuSt haVe

and diSCloSe hiS/her SoCial SeCurity nuMBer.

CMS-855B (02/08) (EF 07/09) 29

SeCtion 15: CertifiCation StateMent (Continued)

a. additional reQuireMentS for MediCare enrollMent

These are additional requirements that the supplier must meet and maintain in order to bill the Medicare
program. Read these requirements carefully. By signing, the supplier is attesting to having read the
requirements and understanding them.

By his/her signature(s), the authorized official(s) named below and the delegated official(s) named in
Section 16 agree to adhere to the following requirements stated in this Certification Statement:

1. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the
Medicare contractor of any future changes to the information contained in this application in accordance
with the timeframes established in 42 C.F.R. § 424.516. I understand that any change in the business
structure of this supplier may require the submission of a new application.

2. I have read and understand the Penalties for Falsifying Information, as printed in this application. I
understand that any deliberate omission, misrepresentation, or falsification of any information contained
in this application or contained in any communication supplying information to Medicare, or any
deliberate alteration of any text on this application form, may be punished by criminal, civil, or
administrative penalties including, but not limited to, the denial or revocation of Medicare billing
privileges, and/or the imposition of fines, civil damages, and/or imprisonment.

3. I agree to abide by the Medicare laws, regulations and program instructions that apply to this supplier.
The Medicare laws, regulations, and program instructions are available through the Medicare contractor. I
understand that payment of a claim by Medicare is conditioned upon the claim and the underlying
transaction complying with such laws, regulations, and program instructions (including, but not limited
to, the Federal anti-kickback statute and the Stark law), and on the supplier’s compliance with all
applicable conditions of participation in Medicare.

4. Neither this supplier, nor any five percent or greater owner, partner, officer, director, managing
employee, authorized official, or delegated official thereof is currently sanctioned, suspended, debarred,
or excluded by the Medicare or State Health Care Program, e.g., Medicaid program, or any other Federal
program, or is otherwise prohibited from supplying services to Medicare or other Federal program
beneficiaries.

5. I agree that any existing or future overpayment made to the supplier by the Medicare program may be
recouped by Medicare through the withholding of future payments.

6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare,
and I will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity.

7. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting
the Medicare program participation requirements, to release to any authorized representative, employee,
or agent of the Centers for Medicare & Medicaid Services (CMS) a copy of my most recent accreditation
survey, together with any information related to the survey that CMS may require (including corrective
action plans).

CMS-855B (02/08) (EF 07/09) 30

SeCtion 15: CertifiCation StateMent (Continued)

B. 1St authoriZed offiCial Signature

I have read the contents of this application. My signature legally and financially binds this supplier to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete and I authorize the Medicare fee-for-service
contractor to verify this information. If I become aware that any information in this application is not true,
correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact immediately.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

authorized official’s information and Signature

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Telephone Number Title/Position

Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

(blue ink preferred)

C. 2nd authoriZed offiCial Signature

I have read the contents of this application. My signature legally and financially binds this supplier to the
laws, regulations, and program instructions of the Medicare program. By my signature, I certify that the
information contained herein is true, correct, and complete and I authorize the Medicare fee-for-service
contractor to verify this information. If I become aware that any information in this application is not true,
correct, or complete, I agree to notify the Medicare fee-for-service contractor of this fact immediately.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

authorized official’s information and Signature

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Telephone Number Title/Position

Authorized Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed not
original will not be processed. Stamped, faxed or copied signatures will not be accepted.

CMS-855B (02/08) (EF 07/09) 31

SeCtion 16: delegated offiCial (oPtional)

• You are not required to have a delegated official. However, if no delegated official is assigned, the
authorized official(s) will be the only person(s) who can make changes and/or updates to the supplier’s
status in the Medicare program.
• The signature of a delegated official shall have the same force and effect as that of an authorized official,
and shall legally and financially bind the supplier to the laws, regulations, and program instructions of
the Medicare program. By his or her signature, the delegated official certifies that he or she has read the
Certification Statement in Section 15 and agrees to adhere to all of the stated requirements. A delegated
official also certifies that he/she meets the definition of a delegated official. When making changes and/
or updates to the supplier’s enrollment information maintained by the Medicare program, a delegated
official certifies that the information provided is true, correct, and complete.
• Delegated officials being deleted do not have to sign or date this application.
• Independent contractors are not considered “employed” by the supplier, and therefore cannot be
delegated officials.
• The signature(s) of an authorized official in Section 16 constitutes a legal delegation of authority to all
delegated official(s) assigned in Section 16.
• If there are more than two individuals, copy and complete this section for each individual.

a. 1St delegated offiCial Signature

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Delegated Official First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

Telephone Number
Check here if Delegated Official is a W-2 Employee

Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

(blue ink preferred)

CMS-855B (02/08) (EF 07/09) 32

SeCtion 16: delegated offiCial (oPtional)

B. 2nd delegated offiCial Signature

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Delegated Official First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

Telephone Number
Check here if Delegated Official is a W-2 Employee

Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed
not original will not be processed. Stamped, faxed or copied signatures will not be accepted.

CMS-855B (02/08) (EF 07/09) 33

SeCtion 17: SuPPorting doCuMentS

This section lists the documents that, if applicable, must be submitted with this enrollment application. If
you are newly enrolling, or are reactivating or revalidating your enrollment, you must provide all applicable
documents. For changes, only submit documents that are applicable to that change.
the fee-for-service contractor may request, at any time during the enrollment process,
documentation to support or validate information reported on the application.

Mandatory for all ProVider/SuPPlier tyPeS

Completed Form CMS-588, for Electronic Funds Transfer Authorization Agreement. Note: If a
supplier already receives payments electronically and is not making a change to its banking information,
the CMS-588 is not required.

Mandatory for SeleCted ProVider/SuPPlier tyPeS

Copy(s) of all documentation verifying IDTF Supervisory Physician(s) proficiency and/or State licenses or
certification for IDTF non-physician personnel.

Mandatory, if aPPliCaBle
Statement in writing from the bank. If Medicare payment due a supplier of services is being sent to a
bank (or similar financial institution) with whom the supplier has a lending relationship (that is, any
type of loan), then the supplier must provide a statement in writing from the bank (which must be in the
loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables.
Copy(s) of all final adverse action documentation (e.g., notifications, resolutions, and reinstatement letters).
Completed Form(s) CMS 855R, Reassignment of Medicare Benefits.
Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement.
Copy of an attestation for government entities and tribal organizations.
Copy of FAA 135 certificate (air ambulance suppliers).
Copy(s) of comprehensive liability insurance policy (IDTFs only).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated
to 6 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.

do not Mail aPPliCationS to thiS addreSS. Mailing your application to this address will significantly delay application processing.

CMS-855B (02/08) (EF 07/09) 34

 attaChMent 1: aMBulanCe SerViCe SuPPlierS

All ambulance service suppliers enrolling in the Medicare program must complete this attachment.

a. geograPhiC area
This section is to be completed with information about the geographic area in which this company
provides ambulance services. If you are changing, adding, or deleting information, check the applicable
box, furnish the effective date, and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Provide the city/town, State, and ZIP code for all locations where this ambulance company renders services.

note: If the ambulance company has vehicles garaged within a different Medicare contractor’s
jurisdiction, a separate CMS-855B enrollment application must be submitted to that fee-for-service
contractor.

1. initial rePorting and/or additionS

If services are provided in selected cities/towns, provide the locations below. List ZIP codes only if
they are not within the entire city/town.
City/town State ZiP Code
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________

2. deletionS
If services are no longer provided in selected cities/towns, provide the locations below. List ZIP codes
only if they are not within the entire city/town.

City/town State ZiP Code

___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________
___________________________ ___________________________ ___________________________

CMS-855B (02/08) (EF 07/09) 35

attaChMent 1: aMBulanCe SerViCe SuPPlierS (Continued)

B. State liCenSe inforMation

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

Crew members must complete continuing education requirements in accordance with State and local
licensing laws. Evidence of re-certification must be retained with the employer in case it is required by the
Medicare fee-for-service contractor.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Is this ambulance company licensed in the State where services are rendered and billed for? YES NO

If No, explain why:

If YES, provide the license information for the State where this ambulance service supplier will be
rendering services and billing Medicare. Attach a copy of the current State license.
License Number Issuing State (if applicable) Issuing City/Town (if applicable)

Effective Date (mm/dd/yyyy) Expiration Date (mm/dd/yyyy)

C. ParaMediC interCePt SerViCeS inforMation

Paramedic Intercept Services involve an arrangement between a Basic Life Support (BLS) ambulance
company and an Advanced Life Support (ALS) ambulance company whereby the latter provides the ALS
services and the BLS ambulance company provides the transportation component. If such an arrangement
exists between the enrolling ambulance company and another ambulance company, the enrolling ambulance
company must attach a copy of the signed contract. For more information, see 42 C.F.R. 410.40.

If reporting a change to information about a previously reported agreement/contract, check “Change” and
provide the effective date of the change.
Change Effective Date:__________________________
Does this ambulance company currently participate in a paramedic YES NO
intercept services arrangement?

CMS-855B (02/08) (EF 07/09) 36

attaChMent 1: aMBulanCe SerViCe SuPPlierS (Continued)

d. VehiCle inforMation
Complete this section with information about the vehicles used by this ambulance company and the
services they provide. If there is more than one vehicle, copy and complete this section as needed. Attach a
copy of each vehicle registration.
To qualify as an air ambulance supplier, the following is required:
• A written statement, signed by the President, Chief Executive Officer or Chief Operating Officer of
the airport from where the aircraft is hangared that gives the name and address of the facility, and
• Proof that the enrolling ambulance company, or the company leasing the air ambulance vehicle to
the enrolling ambulance company, possesses a valid charter flight license (FAA 135 Certificate) for
the aircraft being used as an air ambulance. If the enrolling ambulance company owns the aircraft,
the owner’s name on the FAA 135 Certificate must be the same as the enrolling ambulance company’s
name (or the ambulance company owner as reported in Sections 5 or 6) in this application. If the
enrolling ambulance company leases the aircraft from another company, a copy of the lease
agreement must accompany this enrollment application.

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

Type (automobile, aircraft, boat, etc.) Vehicle Identification Number

Make (e.g., Ford) Model (e.g., 350T) Year (yyyy)

Does this vehicle provide:

Advanced life support (Level 1) YES NO Specialty care transport YES NO
Advanced life support (Level 2) YES NO Land ambulance YES NO
Basic life support YES NO Air ambulance–fixed wing YES NO
Emergency runs YES NO Air ambulance–rotary wing YES NO
Non-emergency runs YES NO Marine ambulance YES NO

CMS-855B (02/08) (EF 07/09) 37

attaChMent 2: indePendent diagnoStiC teSting faCilitieS

indePendent diagnoStiC teSting faCility (idtf) PerforManCe StandardS

Below is a list of the performance standards that an IDTF must meet in order to obtain or maintain their
Medicare billing privileges. These standards, in their entirety, can be found in 42 C.F.R section 410.33(g).
1. Operate its business in compliance with all applicable Federal and State licensure and regulatory

requirements for the health and safety of patients.

2. Provides complete and accurate information on its enrollment application. Changes in ownership, changes
of location, changes in general supervision, and adverse legal actions must be reported to the Medicare
fee-for-service contractor on the Medicare enrollment application within 30 calendar days of the change.
All other changes to the enrollment application must be reported within 90 calendar days.

3. Maintain a physical facility on an appropriate site. For the purposes of this standard, a post office box,

commercial mail box, hotel or motel is not considered an appropriate site.

(i) The physical facility, including mobile units, must contain space for equipment appropriate to the
services designated on the enrollment application, facilities for hand washing, adequate patient
privacy accommodations, and the storage of both business records and current medical records
within the office setting of the IDTF, or IDTF home office, not within the actual mobile unit.
(ii) IDTF suppliers that provide services remotely and do not see beneficiaries at their practice location
are exempt from providing hand washing and adequate patient privacy accommodations.

4. Have all applicable diagnostic testing equipment available at the physical site excluding portable diagnostic
testing equipment. A catalog of portable diagnostic equipment, including diagnostic testing equipment serial
numbers, must be maintained at the physical site. In addition, portable diagnostic testing equipment must
be available for inspection within two business days of a CMS inspection request. The IDTF must maintain
a current inventory of the diagnostic testing equipment, including serial and registration numbers, provide
this information to the designated fee-for-service contractor upon request, and notify the contractor of any
changes in equipment within 90 days.

5. Maintain a primary business phone under the name of the designated business. The primary business phone
must be located at the designated site of the business, or within the home office of the mobile IDTF units.
The telephone number or toll free numbers must be available in a local directory and through directory
assistance.

6. Have a comprehensive liability insurance policy of at least $300,000 per location that covers both the place
of business and all customers and employees of the IDTF. The policy must be carried by a non-relative
owned company. Failure to maintain required insurance at all times will result in revocation of the IDTF’s
billing privileges retroactive to the date the insurance lapsed. IDTF suppliers are responsible for providing
the contact information for the issuing insurance agent and the underwriter. In addition, the IDTF must:
(i) Ensure that the insurance policy must remain in force at all times and provide coverage of at least
$300,000 per incident; and
(ii) Notify the CMS designated contractor in writing of any policy changes or cancellations.

7. Agree not to directly solicit patients, which include, but is not limited to, a prohibition on telephone,
computer, or in-person contacts. The IDTF must accept only those patients referred for diagnostic testing
by an attending physician, who is furnishing a consultation or treating a beneficiary for a specific medical
problem and who uses the results in the management of the beneficiary’s specific medical problem.
Nonphysician practitioners may order tests as set forth in §410.32(a)(3).

CMS-855B (02/08) (EF 07/09) 38

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

8. Answer, document, and maintain documentation of a beneficiary’s written clinical complaint at the physical
site of the IDTF (For mobile IDTFs, this documentation would be stored at their home office.) This includes,
but is not limited to, the following:
(i) The name, address, telephone number, and health insurance claim number of the beneficiary.
(ii) The date the complaint was received; the name of the person receiving the complaint; and a
summary of actions taken to resolve the complaint.
(iii) If an investigation was not conducted, the name of the person making the decision and the reason
for the decision.

9. Openly post these standards for review by patients and the public.

10. Disclose to the government any person having ownership, financial, or control interest or any other legal
interest in the supplier at the time of enrollment or within 30 days of a change.

11. Have its testing equipment calibrated and maintained per equipment instructions and in compliance with
applicable manufacturers suggested maintenance and calibration standards.

12. Have technical staff on duty with the appropriate credentials to perform tests. The IDTF must be able to
produce the applicable Federal or State licenses or certifications of the individuals performing these services.

13. Have proper medical record storage and be able to retrieve medical records upon request from CMS or its
fee-for-service contractor within 2 business days.

14. Permit CMS, including its agents, or its designated fee-for-service contractors, to conduct unannounced,
on-site inspections to confirm the IDTF’s compliance with these standards. The IDTF must be accessible
during regular business hours to CMS and beneficiaries and must maintain a visible sign posting the normal
business hours of the IDTF.

15. With the exception of hospital-based and mobile IDTFs, a fixed base IDTF does not include the following:
(i) Sharing a practice location with another Medicare-enrolled individual or organization.
(ii) Leasing or subleasing its operations or its practice location to another Medicare enrolled individual
or organization.
(iii) Sharing diagnostic testing equipment using in the initial diagnostic test with another Medicare-
enrolled individual or organization.

16. Enrolls in Medicare for any diagnostic testing services that it furnishes to a Medicare beneficiary, regardless
of whether the service is furnished in a mobile or fixed base location.

17. Bills for all mobile diagnostic services that are furnished to a Medicare beneficiary, unless the mobile
diagnostic service is part of a service provided under arrangement as described in section 1861(w)(1) of
the Act.

CMS-855B (02/08) (EF 07/09) 39

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

inStruCtionS
If you perform diagnostic tests, other than clinical laboratory or pathology tests, and are required to enroll as
an IDTF, you must complete this attachment. CMS requires the information in this attachment to determine
whether the enrolling supplier meets all IDTF standards including, but not limited to, those listed on page 38 of
this application. Not all suppliers that perform diagnostic tests are required to enroll as an IDTF

diagnoStiC radiology
Many diagnostic tests are radiological procedures that require the professional services of a radiologist. A
radiologist’s practice is generally different from those of other physicians because radiologists usually do
not bill E&M codes or treat a patient’s medical condition on an ongoing basis. A radiologist or group practice
of radiologists is not necessarily required to enroll as an IDTF. If enrolling as a diagnostic radiology group
practice or clinic and billing for the technical component of diagnostic radiological tests without enrolling as an
IDTF (if the entity is a free standing diagnostic facility), it should contact the carrier to determine that it does
not need to enroll as an IDTF.

A mobile IDTF that provides X-ray services is not classified as a portable X-ray supplier.

Regulations governing IDTFs can be found at 42 C.F.R. 410.33.

CPt-4 and hCPCS Codes—Report all CPT-4 and HCPCS codes for which this IDTF will bill Medicare.
Include the following:
• Provide the CPT-4 or HCPCS codes for which this IDTF intends to bill Medicare,
• The name and type of equipment used to perform the reported procedure, and
• The model number of the reported equipment.

The IDTF should report all Current Procedural Terminology, Version 4 (CPT-4) codes, Healthcare Common
Procedural Coding System codes (HCPCS), and types of equipment (including the model number), for which it
will perform tests, supervise, interpret, and/or bill. All codes reported must be for diagnostic tests that an IDTF
is allowed to perform. Diagnostic tests that are clearly surgical in nature, which must be performed in a hospital
or ambulatory surgical center, should not be reported.

Consistent with IDTF supplier standard 6 on page 38 of this application, all IDTFs enrolling in Medicare must
have a comprehensive liability insurance policy of at least $300,000 per location, that covers both the place of
business and all customers and employees of the IDTF. The policy must be carried by a non-relative owned
company. Failure to maintain the required insurance at all times will result in revocation of the Medicare
supplier billing number, retroactive to the date the insurance lapsed. Malpractice insurance policies do not
demonstrate compliance with this requirement.

All IDTFs must submit a complete copy of the aforementioned liability insurance policy with this application.

CMS-855B (02/08) (EF 07/09) 40

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

a. StandardS QualifiCationS
Provide the date this Independent Diagnostic Testing Facility met all current CMS standards
(mm/dd/yyyy): __________________________________

B. CPt-4 and hCPCS CodeS

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.
CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

All codes reported here must be for diagnostic tests that an IDTF is allowed to perform. Diagnostic tests
that are clearly surgical in nature, which must be performed in a hospital or ambulatory surgical center,
should not be reported. Clinical laboratory and pathology codes should not be reported. This page may be
copied for additional codes or equipment.

CPt–4 or hCPCS Code equipment Model number

(required)

1.________________________________ ______________________________ ______________________________

2.________________________________ ______________________________ ______________________________

3.________________________________ ______________________________ ______________________________

4.________________________________ ______________________________ ______________________________

5.________________________________ ______________________________ ______________________________

6.________________________________ ______________________________ ______________________________

7.________________________________ ______________________________ ______________________________

8.________________________________ ______________________________ ______________________________

9.________________________________ ______________________________ ______________________________

10.________________________________ ______________________________ ______________________________

11.________________________________ ______________________________ ______________________________

12.________________________________ ______________________________ ______________________________

13.________________________________ ______________________________ ______________________________

14.________________________________ ______________________________ ______________________________

15.________________________________ ______________________________ ______________________________

CMS-855B (02/08) (EF 07/09) 41

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

C. interPreting PhySiCian inforMation

CheCK here if this section does not apply because the interpreting physician will bill separate from
the IDTF.
All physicians whose interpretations will be billed by this IDTF with the technical component (TC) of the
test (i.e., global billing) must be listed in this section. If there are more than three physicians, copy and
complete this section as needed. All interpreting physicians must be currently enrolled in the Medicare program.
If you are billing for interpretations as an individual reassigning benefits, the interpreting physician must
complete the Reassignment of Benefits Form (CMS 855R). Note: Both the IDTF and individual physician
must be enrolled with the fee-for-service contractor where the IDTF is located.
If you are billing for purchased interpretations, all requirements for purchased interpretations must be met.
When a mobile unit of the IDTF performs a technical component of a diagnostic test and the interpretive
physician is the same physician who ordered the test, the IDTF cannot bill for the interpretation. Therefore,
these interpreting physicians should not be reported since the interpretive physician must submit his/her
own claims for these tests.

1St interPreting PhySiCian inforMation

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued) NPI

2nd interPreting PhySiCian inforMation

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued) NPI

CMS-855B (02/08) (EF 07/09) 42

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

3rd interPreting PhySiCian inforMation

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued) NPI

d. PerSonnel (teChniCianS) who PerforM teStS

Complete this section with information about all non-physician personnel who perform tests for this IDTF.
Notarized or certified true copies of the State license or certificate should be attached.

1St PerSonnel (teChniCian) inforMation

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) (Required)

Is this technician State licensed or State certified? (see instructions for clarification) YES NO

License/Certification Number (if applicable) License/Certification Issue Date (mm/dd/yyyy) (if applicable)

Is this technician certified by a national credentialing organization? YES NO

Name of credentialing organization (if applicable) Type of Credentials (if applicable)

Is this technician employed by a hospital? YES NO

If yeS, provide the name of the hospital here: ________________________________________________________________

CMS-855B (02/08) (EF 07/09) 43

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

2nd PerSonnel (teChniCian) inforMation

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) (Required)

Is this technician State licensed or State certified? (see instructions for clarification) YES NO

License/Certification Number (if applicable) License/Certification Issue Date (mm/dd/yyyy) (if applicable)

Is this technician certified by a national credentialing organization? YES NO

Name of credentialing organization (if applicable) Type of Credentials (if applicable)

Is this technician employed by a hospital? YES NO

If yeS, provide the name of the hospital here: ________________________________________________________________

e. SuPerViSing PhySiCianS
Complete this section with identifying information about the physician(s) who supervise the operation of
the IDTF and who provides the personal, direct, or general supervision per 42 C.F.R. 410.32(b)(3). The
supervising physician must also attest to his/her supervising responsibilities for the enrolling IDTF.
Information concerning the type of supervision (personal, direct, or general) required for performance of
specific IDTF tests can be obtained from your Medicare fee-for-service contractor. All IDTFs must report at
least one supervisory physician, and at least one supervising physician must perform the supervision requirements
stated in 42 C.F.R. 410.32(b)(3). All supervisory physician(s) must be currently enrolled in Medicare.
The type of supervision being performed by each physician who signs the attestation on page 44 of this
application should be listed in this section.
Definitions of the types of supervision are as follows:
Personal Supervision means a physician must be in attendance in the room during the performance
of the procedure.
direct Supervision means the physician must be present in the office suite and immediately available
to provide assistance and direction throughout the performance of the procedure. It does not mean that
the physician must be present in the room when the procedure is performed.
general Supervision means the procedure is provided under the physician’s overall direction and
control, but the physician’s presence is not required during the performance of the procedure. General
supervision also includes the responsibility that the non-physician personnel who perform the tests are
qualified and properly trained and that the equipment is operated properly, maintained, calibrated and
that necessary supplies are available.
CMS-855B (02/08) (EF 07/09) 44
attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

e. SuPerViSing PhySiCianS (Continued)

If you are changing, adding, or deleting information, check the applicable box, furnish the effective date,
and complete the appropriate fields in this section.

CheCK one CHANGE ADD DELETE

date (mm/dd/yyyy)

First Name Middle Initial Last Name Suffix (e.g., Jr., Sr.)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) (Required)

Medicare Identification Number (if issued) NPI

Telephone Number Fax Number (if applicable) E-mail Address (if applicable)

tyPe of SuPerViSion ProVided

Check the appropriate box below indicating the type of supervision provided by the physician reported
above for the tests performed by the IDTF in accordance with 42 C.F.R. 410.32 (b)(3) (See instructions for
definitions).
Personal Supervision Direct Supervision General Supervision

For each physician performing General Supervision, at least one of the three functions listed here must be

checked. However, to meet the General Supervision requirement, in accordance with 42 C.F.R. 410.33(b),

the enrolling IDTF must have at least one supervisory physician for each of the three functions. For example,

two physicians may be responsible for function 1, a third physician may be responsible for function 2, and

a fourth physician may be responsible for function 3. All four supervisory physicians must complete and

sign the supervisory physician section of this application. Each physician should only check the function(s)

he/she actually performs.

Assumes responsibility for the overall direction and control of the quality of testing performed.
Assumes responsibility for assuring that the non-physician personnel who actually perform the
diagnostic procedures are properly trained and meet required qualifications.
Assumes responsibility for the proper maintenance and calibration of the equipment and supplies
necessary to perform the diagnostic procedures.
other SuPerViSion SiteS
Does this supervising physician provide supervision at any other IDTF? YES NO

If yes, list all other IDTFs for which this physician provides supervision. For more than five, copy this sheet.

name of facility address tax identification number level of Supervision

1.____________________________________________________________________________________________________
2.____________________________________________________________________________________________________
3.____________________________________________________________________________________________________
4.____________________________________________________________________________________________________

5.____________________________________________________________________________________________________

CMS-855B (02/08) (EF 07/09) 45

attaChMent 2: indePendent diagnoStiC teSting faCilitieS (Continued)

e. SuPerViSing PhySiCianS (Continued)

atteStation StateMent for SuPerViSing PhySiCianS

All Supervising Physician(s) rendering supervisory services for this IDTF must sign and date this section.
All signatures must be original.

1. I hereby acknowledge that I have agreed to provide (IDTF Name)________________________________

with the Supervisory Physician services checked above for all CPT-4 and HCPCS codes reported in
this Attachment. (See number 2 below if all reported CPT-4 and HCPCS codes do not apply). I also
hereby certify that I have the required proficiency in the performance and interpretation of each type
of diagnostic procedure, as reported by CPT-4 or HCPCS code in this Attachment (except for those
CPT-4 or HCPCS codes identified in number 2 below). I have read and understand the Penalties for
Falsifying Information on this Enrollment Application, as stated in Section 14 of this application. I am
aware that falsifying information may result in fines and/or imprisonment. If I undertake supervisory
responsibility at any additional IDTFs, I understand that it is my responsibility to notify this IDTF
at that time.

2. I am not acting as a Supervising Physician for the following CPT-4 and/or HCPCS codes reported in

this Attachment.

CPt–4 or hCPCS Code CPt–4 or hCPCS Code CPt–4 or hCPCS Code

__________________________ ___________________________ ___________________________

__________________________ ___________________________ ___________________________
__________________________ ___________________________ ___________________________
__________________________ ___________________________ ___________________________

3. Signature of Supervising Physician (First, Middle, Last, Jr., Sr., M.D., D.O., etc.) Date (mm/dd/yyyy)

all signatures must be original and signed and dated in ink (blue ink preferred).
applications with signatures deemed not original will not be processed.
Stamped, faxed or copied signatures will not be accepted.

CMS-855B (02/08) (EF 07/09) 46

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MediCare SuPPlier enrollMent aPPliCation

PriVaCy aCt StateMent

The Centers for Medicare and Medicaid Services (CMS) is authorized to collect the information requested on this form by sections
1124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42 U.S.C. §§ 1320a-3(a)(1), 1320a-
7, 1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt Collection Improvement Act [31 U.S.C. § 7701(c)].

The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in
the Medicare program as suppliers of goods and services to Medicare beneficiaries and to assist in the administration of the
Medicare program. This information will also be used to ensure that no payments will be made to providers who are excluded
from participation in the Medicare program. All information on this form is required, with the exception of those sections
marked as “optional” on the form. Without this information, the ability to make payments will be delayed or denied.

The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS), and system
number 09-70-0525 titled Unique Physician/Practitioner Identification Number (UPIN) System (published in Vol. 61 of the
Federal Register at page 20,528 (May 7, 1996)). The information in this application will be disclosed according to the routine
uses described below.

Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
2. A congressional office from the record of an individual health care provider in response to an inquiry from the
congressional office at the written request of that individual health care practitioner;
3. The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
4. Peer Review Organizations in connection with the review of claims, or in connection with studies or other review
activities, conducted pursuant to Part B of Title XVIII of the Social Security Act;
5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States
Government is a party to litigation and the use of the information is compatible with the purpose for which the agency
collected the information;
6. To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which criminal
penalties are attached;
7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique
Physician Identification Number Registry is unable to establish identity after matching contractor submitted data to the
data extract provided by the AMA;
8. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or
disability, or to the restoration or maintenance of health;
9. Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers of medical

services or to detect fraud or abuse;

10.
State Licensing Boards for review of unethical practices or non-professional conduct;
11.
States for the purpose of administration of health care programs; and/or
12. Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care

groups providing health care claims processing, when a link to Medicare or Medicaid claims is established, and data are

used solely to process supplier’s health care claims.

The enrolling supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503)
amended the Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through computer matching.

Protection of Proprietary information

Privileged or confidential commercial or financial information collected in this form is protected from public disclosure by
Federal law 5 U.S.C. § 552(b)(4) and Executive Order 12600.

Protection of Confidential Commercial and/or Sensitive Personal information

If any information within this application (or attachments thereto) constitutes a trade secret or privileged or confidential information
(as such terms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal
nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then
such information will be protected from release by CMS under 5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.
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