All medical professionals that provide Medicare services must complete a CMS-855I enrollment application.
All physicians and non-physician medical personnel that wish to be compensated for Medicare health services must file a CMS-855I enrollment application with the Centers for Medicare & Medicaid Services. The CMS-855I form can be used for both new applications and modifications of existing enrollment information. Once you have completed the form, you'll need to send the original copy to your state's Medicare administrative contractor, who will handle all payments to you and your practice.
Instructions
1. Obtain a National Provider Identification (NPI) from the National Plan and Provider Enumeration System (NPPES), if you don't have one already. You may apply for an NPI online at the NPPES website (see Resources).
2. Indicate the reason that you are submitting a CMS-855I as requested in Section 1 of the form. If you are amending an existing Medicare registration then you only need to complete certain sections, as indicated by Item B. If you are completing a new application, then you must fill out the entire form.
3. Provide all identifying and professional information required by Section 2. If you are a physician's assistant, you will need to provide your employer's name and NPI to complete items E through F.
4. Furnish information on any adverse professional events that you have experienced in Section 3. Events that must be reported include felony convictions, misdemeanor convictions related to health care service, revocations of a federal or state license or accreditation, and any Medicare payments that have been suspended.
5. Detail all locations in which you see patients or store medical records in Section 4.
6. Report all employees that directly manage you in Section 6. If your manager has had any adverse events, such as license revocations or criminal convictions, then you will need to report those events in this section.
7. Provide information about the billing agency that you use in Section 8. If you don't use a billing agency, then you can skip this step.
8. Provide information for a contact person regarding your Medicare application in Section 13. If you want the CMS to contact you directly, then you can skip this step.
9. Read all information in Section 14. This section describes actions that constitute Medicare application fraud. It also discusses the penalties that you may face if you provide the CMS with false information.
10. Read the certification statement provided in Section 15. Sign and date at the bottom of the section.
11. Attach necessary supporting documents as designated in Section 17. If you are filing new bank account information, then you will need to attach the CMS-588 Electronic Funds Transfer Authorization Agreement. You will also need to provide information on any adverse events noted in your application.
12. Mail the completed application to your state's Medicare administrative contractor. You may locate the address for your state's contractor via the CMS website (see Resources).
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