This tutorial has been created to assist you in completing the paper form CMS- I Physician and Non-Physician Practitioners Enrollment Application. You can also enroll in Medicare by filling out these forms electronically, online, using CMSI. Physicians and Non-Physician Practitioners. Physicians and . Education Department along with the Provider Enrollment. Department in an attempt to assist you with correctly completing the CMSI enrollment form the .

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Question 1 must be answered. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval.

Complete this application if you are an individual practitioner who plans to bill Medicare and you are: Applicants who have never enrolled with the Medicare program in any state, or who are changing specialty types not MD’s or DO’s will mark this box.

Reassignment of Medicare Benefits. If any of your payments are part of your private practice and a group organization furnish the name and Medicare identification number s and NPI of each group or organization below and continue to Section 4C where you will enter your private practice information.

Applications are available at the AMA Web site, http: No portion of the From copyrighted materials contained within this publication may be copied without the express written consent of the AHA.

If this section applies to you, be sure the legal business name is listed as it appears with the IRS.

CMS form 855I for new Medicare program enrollees

Did you identify any final adverse actions that have been imposed against those individuals in 6A, attach a copy of the final adverse action documentation and resolution? Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMSI.

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In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material.

Additionally, ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. Jurisdiction H Mailing Addresses. Institutional Providers Institutional providers can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the Corm. Each new idea, self-service tool, or new article depends on you and your participation in our ForeSee customer satisfaction survey.

Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. Government information system, CMS maintains ownership and responsibility for its computer systems. If formm as a sole practitioner or your organization sees patients in more than one location, complete this section for each location. Institutional providers can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMSA.

To learn more about the information that is required for each section of the CMSI form, please click on the appropriate part as outlined in the table below.

Complete this application if you are an individual practitioner who plans to bill Medicare and you are:. The following chart describes when and how First Coast will contact providers based on the contact information provided in your enrollment application.

The address cannot be a billing agency’s address.

If you are reassigning all of your Medicare benefits per Section 4B1 of this applicationdid you furnish both your Medicare identification number if issued and your NPI on page 3, Section 1A, in the two spaces provided within the second paragraph at the top of the page?

Check the appropriate boxes on page 5 identifying what information is changing.

A medical practice or clinic that will bill for Medicare Part B services e. Physician Assistants must complete Section 2e to establish employment arrangement s or Section 2f to terminate the employment arrangement s. Select which best describes you: Jurisdiction L Mailing Addresses. AHA copyrighted materials including the UB codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA.

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Reason for Application Who Should Complete This Section “You are a new enrollee in Medicare” Applicants who have never enrolled with the Medicare program in any state, or who are changing specialty types not MD’s or DO’s will mark this box “You are enrolling with another fee-for-service contractor” Applicants who have enrolled with other contractors, but are now enrolling with Noridian will mark this box. Information for Medicare beneficiaries is only available on the medicare.

Section D Medical Specialties: End Users do not act for or on behalf of the CMS. An individual who has formed a professional corporation, professional association, limited liability company, etc.

CMS form I for new Medicare program enrollees –

The use of the information system establishes user’s consent to any and all monitoring and recording of their activities. Supporting Documents Some supporting documentation requirements may change due to the laws in your state. Section 4 – Practice Location Information. Any communication or data transiting or stored on this system may be disclosed or used for any lawful Government purpose.

Used for additional information requests 855i the contact information on the application is incomplete. Last Updated Feb 01, Did you complete Section 4A on fkrm 14, if you are the sole owner of a professional corporationa professional associationor a limited liability company intending to bill Medicare through this business entity?