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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State Street, Chicago, IL Search Term Select site section to search: An individual practitioner who will provide services in a group setting Sections 1 — 4 and 14 – 17 only.

Some supporting documentation requirements may change due to the laws in your state. User License Agreement and Consent to Monitoring.

You will need to mail the completed, signed form and all supporting documentation to Novitas Solutions. Forms, whether paper or electronic, must be completed by all providers of services and suppliers of medical and other health services for enrollment in the Medicare program. Did you complete Section cmss questions on page 10, if you are a psychologist billing independently.

This website provides information and news about the Medicare program for health care professionals only. 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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Department of Defense procurements and the limited rights restrictions of FAR Vms your feedback, click here to take the survey now.

All unsolicited revalidation applications submitted more than 6 months in advance of your due date will be returned. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.

Help us make your experience better. Refer to our Medical Specialties list on our website for all specialties that can enroll with Medicare Part B. If you do not use a billing agency, you can continue with Section 13 on page An individual who has formed a professional corporation, professional association, limited liability company, etc.

Please indicate your personal NPI number in section 1.

CMS form 855I for new Medicare program enrollees

Did you fill in Section 4E on page 18 regarding your cs to have your special payment address mirror your practice location address, or to be different from that? 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.

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. Florida Puerto Rico U. If there is more than one managing employee, copy and complete this section as needed.

Reassignment of Medicare Benefits. No fee schedules, basic unit, relative values or related listings are included in CDT.

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Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. Applicants choosing to close their number will check this box.

CMS form I for new Medicare program enrollees –

All signatures must be original. 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. Check the appropriate boxes on page frm identifying what information is gorm. This license will terminate upon notice to you if you violate the terms of this license. Select your line of business: Applicants will mark this box if they were previously enrolled in Medicare, but their number s was were deactivated.

Indian Health Service Mailing Addresses. 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. Section B Correspondence Address: Jurisdiction H Mailing Addresses.

Applicants who have enrolled with other contractors, but are now enrolling with Noridian will mark this box.