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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Applications are available at the AMA Web site, http: Did you designate your primary specialty only forn and your secondary specialties one or more on page 7, Section 2D Medical Specialtiesquestion 1. This is a list of supporting documents which are often missed. 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.

If you checked Diagnostic Radiology as your specialty, and you will be billing Medicare for the technical component of the diagnostic tests, did you also complete a CMSB enrollment form as an independent diagnostic testing facility IDTF? An individual practitioner who will forrm services in a private setting. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: This website is intended exclusively for Medicare providers and health care industry professionals to find foem latest Medicare news and information affecting the provider community.

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Enrollment Forms (CMS)

Reassignment of Medicare Benefits. Help us make your experience better. If you have a second specialty, enter an S in the box next to your secondary specialty.

All cks must be original. Consent to Monitoring Warning: If you choose not to accept the agreement, you will return to the Noridian Medicare home page.

If this is a U. The ADA is a third-party beneficiary to this Agreement. Physician Assistants must complete Section 2e to establish employment arrangement s or Section 2f to terminate the employment foem s.

An additional CMSI must be completed for each non-physician specialty type. This system is provided for Government authorized use only. Did you fill in Section 4E on page 18 regarding your option to have your special payment address mirror your practice location address, or to be different from that?

Government information system, CMS maintains ownership and responsibility for its computer systems. AMA Disclaimer of Warranties and Liabilities CPT is provided “as is” without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. This license will terminate upon notice to you if you violate the terms of this license.

CMS form 855I for new Medicare program enrollees

If the answer is YES, complete question 2 and attach documentation and information about the resolution for each adverse legal action.

If yes, did you attach a copy of the final adverse action documentation and its resolution? If the individual does not want to be in a participating status with Medicare, they should submit a letter stating they wish to be Nonparticipating. Applicants will mark this box if they were cmz enrolled in Medicare, but their number s was were deactivated.


Currently enrolled in Medicare and need to make changes to your 85i enrollment information. 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 Physicians and 855j practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMSI. Currently enrolled as an MDPP supplier with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction e.

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

Reaching the contact is extremely important, especially if enrollment has any questions regarding the submitted information. Section 17 – Supporting Documents. Indian Health Service Mailing Addresses.

CMS I Instructions – Noridian

There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. Did you fill in your personal information on page 5 in Section 2A, Identifying Informationrelative to yourself as well as to your license and rorm information? Did you include the name s of all managing employees?

This Agreement will terminate upon notice to you if you violate the terms of this Agreement.