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1 maj 2023 · CMS 855I Dynamic List Information ... 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. 2026-05-01. Special Instructions. N/A. Downloads. CMS 855i; Get email updates. Sign up to get the latest information about your ...
- Enrollment Applications
The following forms can be used for initial enrollment,...
- Enrollment Applications
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.
8 gru 2021 · Make Changes to Provider Information. It is important to keep your Medicare Information up to date. You can quickly and easily update this information on the PECOS webpage. Submitting applications via Internet-based Provider Enrollment, Chain and Ownership System (PECOS) Web is the preferred method.
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:
If you don’t use PECOS, use the revised CMS-855I (Medicare Enrollment Application - Physicians and non-physician practitioners) to enroll or update your information. Medicare administrative contractors will accept current and revised versions of the form through October 31, 2023.
All physicians and non-physician practitioners must complete the Medicare Enrollment Application - Physicians and Non-Physician Practitioners (CMS-855I) application in order to initiate the enrollment process and, as applicable, wish to reassign their benefits under § 424.80.
The 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.
