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1 maj 2023 · CMS forms; CMS forms list; Beneficiary Notices Initiative (BNI) Health & drug plans. Back to menu ... CMS 855I Dynamic List Information. Dynamic List Data. Form # CMS 855I. Form Title. Medicare Enrollment Application - Physicians and Non-Physician Practitioners. Revision Date. 2023-05-01. O.M.B. # 0938-1355. O.M.B. Expiration Date.
The CMS-855R (Reassignment of Medicare Benefits) form has been discontinued. For additional information regarding the Medicare enrollment process (including Internet-based PECOS) and to get the current version of the CMS-855I, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.
All physicians and non-physician practitioners must complete the Medicare Enrollment Application - Physicians and Non-Physician Practitioners (CMS-855I) application in order to initiate the enrollment process and, as applicable, wish to reassign their benefits under § 424.80.
Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either: • TheInternet-basedProvider Enrollment, Chain and Ownership System (PECOS), or • Thepaper enrollment application process (e.g., CMS 855I).
Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855I. Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
The following forms can be used for initial enrollment, revalidations, changes in status, and voluntary termination: CMS-855A (PDF) for Institutional Providers. CMS-855B (PDF) for Clinics, Group Practices, and Certain Other Suppliers. CMS-855I (PDF) for Physicians and Non-Physician Practitioners.
27 wrz 2024 · CMS-855I. Who Should Complete This Application? All individuals (physicians and NPPs) in private practice as a sole owner or sole proprietorship. All individuals (physician and NPPs) who reassign benefits with an entity/individual.
