cms-855i form - centers for medicare and medicaid … see page 1 to ... , use the cms-855r to submit...

MEdiCarE EnrollMEnt aPPliCation

PhySiCianS and non-PhySiCian PraCtitionErS

CMS-855i

SEE PagE 1 to dEtErMinE if you arE CoMPlEting thE CorrECt aPPliCation.

SEE PagE 2 for inforMation on whErE to Mail thiS aPPliCation.

SEE PagE 26 to find thE liSt of thE SuPPorting doCuMEntation that MuSt bE SubMittEd with thiS aPPliCation.

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved OMB No. 0938-0685Expires: 08/19

who Should CoMPlEtE thiS aPPliCation

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either:• TheInternet-basedProviderEnrollment,ChainandOwnershipSystem(PECOS),or• Thepaperenrollmentapplicationprocess(e.g.,CMS855I).

ForadditionalinformationregardingtheMedicareenrollmentprocess,includingInternet-basedPECOS,goto http://www.cms.gov/MedicareProviderSupEnroll/.

Physiciansandnon-physicianpractitionerswhoareenrolledintheMedicareprogram,buthavenotsubmittedtheCMS855Isince2003,arerequiredtosubmitaMedicareenrollmentapplication(i.e.,Internet-basedPECOSortheCMS855I)asaninitialapplicationwhenreportingachangeforthefirsttime.

Allphysicians,aswellasallnon-physicianpractitionerslistedbelow,mustcompletethisapplicationtoinitiate the enrollment process:

Anesthesiology Assistant Massimmunizationrosterbiller Psychologist,ClinicalAudiologist Nurse practitioner PsychologistbillingCertifiednursemidwife Occupationaltherapistin independentlyCertifiedregisterednurse privatepractice Registered Dietitian or

anesthetist Physical therapist in Nutrition Professional Clinicalnursespecialist privatepractice SpeechLanguagePathologistClinicalsocialworker Physician assistant Ifyoursuppliertypeisnotlistedabove,contactyourdesignatedfee-for-servicecontractorbeforeyousubmitthisapplication.

CompletethisapplicationifyouareanindividualpractitionerwhoplanstobillMedicareand you are:• Anindividualpractitionerwhowillprovideservicesinaprivatesetting.• Anindividualpractitionerwhowillprovideservicesinagroupsetting.Ifyouplantorenderallof yourservicesinagroupsetting,youwillcompleteSections1-4andskiptoSections14through17 ofthisapplication.

• CurrentlyenrolledwithaMedicarefee-for-servicecontractorbutneedtoenrollinanotherfee-for- servicecontractor’sjurisdiction(e.g.,youhaveopenedapracticelocationinageographicterritoryservicedbyanotherMedicarefee-for-servicecontractor).

• CurrentlyenrolledinMedicareandneedtomakechangestoyourenrollmentinformation(e.g.,you haveaddedorchangedapracticelocation).

• Anindividualwhohasformedaprofessionalcorporation,professionalassociation,limitedliability company,etc.,ofwhichyouarethesoleowner.

Ifyouprovideservicesinagroup/organizationsetting,youwillalsoneedtocompleteaseparate application,theCMS-855R,toreassignyourbenefitstoeachorganization.Ifyouterminateyour associationwithanorganization,usetheCMS-855Rtosubmitthatchange.

CMS-855I (07/11) 1

http://www.cms.gov/MedicareProviderSupEnroll/

billing nuMbEr inforMation

TheNationalProviderIdentifier(NPI)isthestandarduniquehealthidentifierforhealthcareprovidersandisassignedbytheNationalPlanandProviderEnumerationSystem(NPPES).As a Medicare healthcare supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change to yourexisting Medicare enrollment information.ApplyingfortheNPIisaprocessseparatefromMedicareenrollment.ToobtainanNPI,youmayapplyonlineathttps://NPPES.cms.gov.Formoreinformationabout NPIenumeration,visitwww.cms.gov/NationalProvIdentStand. TheMedicareIdentificationNumber,oftenreferredtoasaProviderTransactionAccessNumber(PTAN)orMedicareLegacyNumber,isagenerictermforanynumberotherthantheNPIthatisusedtoidentifyaMedicaresupplier.

inStruCtionS for CoMPlEting and SubMitting thiS aPPliCation

Typeorprintallinformationsothatitislegible.Donotusepencil.• Reportadditionalinformationwithinasectionbycopyingandcompletingthatsectionforeachadditionalentry.

• Attachallrequiredsupportingdocumentation. • KeepacopyofyourcompletedMedicareenrollmentpackageforyourownrecords. • Sendthecompletedapplicationwithoriginalsignaturesandallrequireddocumentationtoyourdesignatedfee-for-servicecontractor.

avoid dElayS in your EnrollMEnt

Toavoiddelaysintheenrollmentprocess,youshould:• Completeallrequiredsections. • EnsurethatthecorrespondenceaddressshowninSection2isthesupplier’saddress. • EnteryourNPIintheapplicablesections. • Enterallapplicabledates. • Sendthecompletedapplicationwithallsupportingdocumentationtoyourdesignatedfee-for-servicecontractor.

additional inforMa tion

ForadditionalinformationregardingtheMedicareenrollmentprocess,visitwww.cms.gov/ MedicareProviderSupEnroll. Thefee-for-servicecontractormayrequest,atanytimeduringtheenrollmentprocess,documentationtosupportandvalidateinformationreportedontheapplication.Youareresponsibleforprovidingthisdocumentationinatimelymanner. Certaininformationyouprovideonthisformisprotectedunder5U.S.C.Section552(b)(4)and/or(b)(6),respectively.Formoreinformation,seethelastpageofthisapplicationtoreadthePrivacyActStatement.

Mail your aPPliCa tion

TheMedicarefee-for-servicecontractor(alsoreferredtoasacarrieroraMedicareadministrativecontractor)thatservicesyourStateisresponsibleforprocessingyourenrollmentapplication.Tolocatethemailingaddressforyourfee-for-servicecontractor,gotowww.cms.gov/MedicareProviderSupEnroll.

CMS-855I (07/11) 2

https://NPPES.cms.gov

http://www.cms.gov/NationalProvIdentStand

http://www.cms.gov/MedicareProviderSupEnroll

http://www.cms.gov/MedicareProviderSupEnroll

SECtion 1: baSiC inforMation a. Check one box and complete the required sections.SincephysicianassistantsdonotcompleteSection4,allphysicianassistantsmustfurnishtheirMedicare

MedicareIdentificationNumber(s):_______________________NPI:_______________________ IdentificationNumber(ifissued)andtheirNPIhere:

IfyouarereassigningallofyourMedicarebenefitspersection4B1ofthisapplication,furnishyour

MedicareIdentificationNumber(s):_______________________NPI:_______________________ MedicareIdentificationNumber(ifissued)andyourindividual(Type1)NPIhere:

rEaSon for aPPliCation billing nuMbEr inforMation rEQuirEd SECtionS

Youareanew enrollee in Medicare

EnteryourMedicareIdentificationNumber(if issued) andtheNPIyouwouldliketolinktothisnumber inSection4.

Complete all applicablesections

Youareenrolling with another fee-for-service contractor



Youarereactivating yourMedicare enrollment



Youarevoluntarilyterminating your Medicareenrollment

Effective Date of Termination: Sections1A, 13 and 15 Physician Assistants mustcompleteSections1A, 2F, 13and 15 EmployersterminatingPhysician Assistants mustcompleteSections1A, 2G, 13and 15

Medicare Identification Number(s) to Terminate (if issued):

National Provider Identifier (if issued):

Youarechanging yourMedicare information

Medicare Identification Number (if issued): GotoSection1B

NPI:

Youarerevalidating yourMedicare enrollment



CMS-855I (07/11) 3

SECtion 1: baSiC inforMation (Continued)

b. Check all that apply and complete the required sections.

rEQuirEd SECtionS

IdentifyingInformation 1, 2 (completeonlythosesectionsthatarechanging),3, 13 and 15

FinalAdverseActions/Convictions 1, 2A, 3, 13 and 15

PracticeLocationInformation,PaymentAddress andMedicalRecordStorageInformation

1, 2A, 3, 4 (completeonlythosesections that are changing),13 and 15

IndividualsHavingManagingControl 1, 2A, 3, 6, 13, and 15

BillingAgencyInformation 1, 2A, 3, 8 (completeonlythosesections that are changing),13 and 15

CMS-855I (07/11) 4

SECtion 2: idEntifying inforMation a. Personal information: your name, date of birth, and social security number must coincide with the information on your social security record.

First Name Middle Initial Last Name Jr., Sr., M.D., D.O., etc.

Other Name, First Middle Initial Last Name Jr., Sr., M.D., D.O., etc.

Other (Describe):____________________________________ Type of Other Name

Professional NameFormer or Maiden Name Date of Birth (mm/dd/yyyy) State of Birth Country of Birth

Gender

Male Female

Social Security Number

Medical or other Professional School (Training Institution, if non-MD)

Year of Graduation (yyyy) DEA Number (if applicable)

license information License Not Applicable

License Number State Where Issued

Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy)

Certification information Certification Not Applicable

Certification Number State Where Issued

Effective Date (mm/dd/yyyy) Expiration/Renewal Date (mm/dd/yyyy)

new Patient Status information Do you accept new Medicare patients? Yes No

b. Correspondence addressProvidecontactinformationforthepersonshowninSection2Aabove.Onceenrolled,theinformationprovidedbelowwillbeusedbythefee-for-servicecontractorifitneedstocontactyoudirectly.Thisaddresscannotbeabillingagency’saddress.

Mailing Address Line 1 (Street Name and Number)

Mailing Address Line 2 (Suite, Room, etc.)

City/Town State ZIP Code + 4

Telephone Number Fax Number (if applicable) E-mail Address (if applicable)

CMS-855I (07/11) 5

SECtion 2: idEntifying inforMation (Continued)

C. resident/fellow Status

1. Areyoucurrentlyinanapprovedtrainingprogramas: a.Aresident? YES NO b.Inafellowshipprogram? YES NO

• IfNO,skiptoSection2D. • IfYEStoeitheroftheabovequestions,providethenameandaddressofthe facilitywhereyouarearesidentorfellowonthefollowinglines:

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

2. AretheservicesthatyourenderatthefacilityshowninSection2C1 YES

DateofCompletion:____________.Ifyourcompletiondateispriortothe beginningdateforyourpracticeinSection4,skiptoSection2D.

NO partofyourrequirementsforgraduationfromaformalresidency orfellowshipprogram?

3. Doyoualsorenderservicesatotherfacilitiesorpracticelocations? YES NO IFYES,youmustreportthesepracticelocationsinSection4.

4.Aretheservicesthatyourenderinanyofthepracticelocationsyouwill YES NO bereportinginSection4partofyourrequirementsforgraduationfromaresidencyorfellowshipprogram?

IFYES,hastheteachinghospitalreportedinSection2C1aboveagreedto YES NO incurallorsubstantiallyallofthecostsoftraininginthenon-hospitalfacility.

CMS-855I (07/11) 6


d. 1. Physician SpecialtyDesignateyourprimaryspecialtyandallsecondaryspecialty(s)belowusing: P=Primary S=Secondary

Youmayselectonlyoneprimaryspecialty.Youmayselectmultiplesecondaryspecialties.AphysicianmustmeetallFederalandStaterequirementsforthetypeofspecialty(s)checked.

Addiction medicine Allergy/Immunology Anesthesiology CardiacElectrophysiology Cardiacsurgery Cardiovasculardisease (Cardiology) Chiropractic Colorectalsurgery(Proctology) Criticalcare(Intensivists) Dermatology Diagnostic radiology Emergencymedicine Endocrinology Family practice Gastroenterology General practice General surgery Geriatric medicine Gynecological oncology Handsurgery Hematology

Hematology/Oncology Hospice Infectiousdisease Internalmedicine InterventionalPain Management Interventionalradiology Maxillofacial surgery Medical oncology Nephrology Neurology Neuropsychiatry Neurosurgery Nuclear medicine Obstetrics/Gynecology Ophthalmology Optometry Oralsurgery(Dentistonly) Orthopedicsurgery OsteopathicManipulativeMedicine Otolaryngology Pain Management

PalliativeCare Pathology Pediatric medicine Peripheralvasculardisease Physical medicineandrehabilitation Plastic and reconstructivesurgery Podiatry Preventivemedicine Psychiatry Psychiatry(geriatric) Pulmonary disease Radiation oncology Rheumatology SportsMedicine Surgicaloncology Thoracicsurgery Urology Vascular surgery

(Specify):__________________

Undefinedphysiciantype

CMS-855I (07/11) 7


d. 2. non–Physician SpecialtyIfyouareanon-physicianpractitioner,checktheappropriateboxtoindicateyourspecialty. Allnon-physicianpractitionersmustmeetspecificlicensing,educational,andworkexperiencerequirements.Ifyouneedinformationconcerningthespecificrequirementsforyourspecialty,contacttheMedicarefee-for-servicecontractor.

Check only one of the following: Ifyouwanttoenrollasmorethanonenon-physicianspecialtytype,youmustsubmitaseparateCMS-855Iapplicationforeach.

Anesthesiology assistantAudiologist Certifiednursemidwife Certifiedregisterednurseanesthetist Clinicalnursespecialist Clinicalsocialworker Massimmunizationrosterbiller Nurse practitioner Occupationaltherapistinprivatepractice Physicaltherapistinprivatepractice Physician assistant Psychologist,clinical Psychologistbillingindependently Registered dietitian or nutrition professional SpeechLanguagePathologist Undefinednon-physicianpractitionertype(Specify):

_______________________________________

_______________________________________

_______________________________________

CMS-855I (07/11) 8


E. Physician assistants: Establishing Employment arrangement(s)

EMPloyEr’S naME EffECtivE datE

of EMPloyMEnt

EMPloyEr’S MEdiCarE idEntifiCation nuMbEr

(if iSSuEd)

EMPloyEr’S nPi

EMPloyEr’S Ein

f. Physician assistants: terminating Employment arrangement(s)Completethissectionifyouareaphysicianassistantdiscontinuingyouremploymentwithapractice.

EMPloyEr’S naME EffECtivE datE

of EMPloyMEnt

EMPloyEr’S MEdiCarE idEntifiCation nuMbEr

(if iSSuEd)

EMPloyEr’S nPi

EMPloyEr’S Ein

g. Employer terminating Employment arrangement with one or More Physician assistantsThissectionshouldbeusedbyanindividualwhohasincorporatedorisasoleproprietor,andwhoisdiscontinuingtheiremploymentarrangementwithaphysicianassistant.

PhySiCianS aSSiStant’S naME EffECtivE datE of dEParturE

PhySiCianS aSSiStant’S MEdiCarE idEntifiCation

nuMbEr a (if iSSuEd)

PhySiCianS aSSiStant’S nPi

CMS-855I (07/11) 9


Doyouholdadoctoraldegreeinpsychology? IfYES,furnishthefieldofyourpsychologydegree__________________________ Attachacopyofthedegreewiththisapplication.

h. Clinical Psychologists

i. Psychologists billing independently1. Doyourenderservicesofyourownresponsibilityfreefromtheadministrative controlofanemployersuchasaphysician,institution,oragency? 2. Doyoutreatyourownpatients? 3. Doyouhavetherighttobilldirectly,andtocollectand retainthefeeforyourservices? 4. Isthisprivatepracticelocatedinaninstitution?

If YES toquestion4above,pleaseanswerquestions“a”and“b”below. a)Ifyourprivatepracticeislocatedinaninstitution,isyourofficeconfined

to a separately identified part of the facility that is used solely as your office andcannotbeconstruedasextendingthroughouttheentireinstitution? b)Ifyourprivatepracticeislocatedinaninstitution,areyourservicesalso renderedtopatientsfromoutsidetheinstitutionorfacilitywhereyour officeislocated?

J. Physical therapists/occupational therapists in Private Practice (Pt/ot)Thefollowingquestionsonlyapplytoyourindividualpractice.Theydonotapplyifyouarereassigningallofyourbenefitstoagroup/organization. 1. AreallofyourPT/OTservicesonlyrenderedinthepatients’homes? 2. Doyoumaintainprivateofficespace? 3. Doyouown,lease,orrentyourprivateofficespace? 4. Isthisprivateofficespaceusedexclusivelyforyourprivatepractice? 5. DoyouprovidePT/OTservicesoutsideofyourofficeand/orpatients’homes? If you respond YES to any of the questions 2–5 above,attachacopyoftheleaseagreementthatgivesyouexclusiveuseofthefacilityforPT/OTservices.

K. nurse Practitioners and Certified Clinical nurse SpecialistsAreyouanemployeeofaMedicareskillednursingfacility(SNF)orofanother entitythathasanagreementtoprovidenursingservicestoaSNF? Ifyes,includetheSNF’snameandaddress.

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

YES NO

Name

Street Address

CMS-855I (07/11) 10

City State Zip


l. advanced diagnostic imaging (adi) Suppliers only

ThissectionmustbecompletedbyallindividualpractitionersthatalsofurnishandwillbillMedicareforADIservices.AllindividualpractitionersfurnishingADIservicesMUSTbeaccreditedineachADIModalitycheckedbelowtoqualifytobillMedicareforthoseservices.

CheckeachADIModalitythatyouwillfurnishandthenameoftheAccreditingOrganizationthataccreditedyouforthatADIModality.

Magnetic resonance imaging (Mri) Name of Accrediting Organization for MRI

Effective Date of Current Accreditation (mm/dd/yyyy) Expiration Date of Current Accreditation (mm/dd/yyyy)

Computed tomography (Ct) Name of Accrediting Organization for CT


nuclear Medicine (nM) Name of Accrediting Organization for NM


Positron Emission tomography (PEt) Name of Accrediting Organization for PET


CMS-855I (07/11) 11

SECtion 3: final advErSE lEgal aCtionS/ConviCtionS

Thissectioncapturesinformationonfinaladverselegalactions,suchasconvictions,exclusions,revocations,andsuspensions.Allapplicablefinaladverseactionsmustbereported,regardlessofwhetheranyrecordswereexpungedoranyappealsarepending.

Convictions 1. Theprovider,supplier,oranyowneroftheproviderorsupplierwas,withinthelast10yearsprecedingenrollmentorrevalidationofenrollment,convictedofaFederalorStatefelonyoffensethatCMShasdeterminedtobedetrimentaltothebestinterestsoftheprogramanditsbeneficiaries.Offensesinclude: Felonycrimesagainstpersonsandothersimilarcrimesforwhichtheindividualwasconvicted,includingguiltypleasandadjudicatedpre-trialdiversions;financialcrimes,suchasextortion, embezzlement,incometaxevasion,insurancefraudandothersimilarcrimesforwhichtheindividualwasconvicted,includingguiltypleasandadjudicatedpre-trialdiversions;anyfelonythatplacedtheMedicareprogramoritsbeneficiariesatimmediaterisk(suchasamalpracticesuitthatresultsinaconvictionofcriminalneglectormisconduct);andanyfeloniesthatwouldresultinamandatoryexclusionunderSection1128(a)oftheSocialSecurityAct.

2. Anymisdemeanorconviction,underFederalorStatelaw,relatedto:(a)thedeliveryofanitemor serviceunderMedicareoraStatehealthcareprogram,or(b)theabuseorneglectofapatientin connectionwiththedeliveryofahealthcareitemorservice.

3. Anymisdemeanorconviction,underFederalorStatelaw,relatedtotheft,fraud,embezzlement, breachoffiduciaryduty,orotherfinancialmisconductinconnectionwiththedeliveryofahealthcareitemorservice.

4. Anyfelonyormisdemeanorconviction,underFederalorStatelaw,relatingtotheinterferencewith orobstructionofanyinvestigationintoanycriminaloffensedescribedin42C.F.R.Section 1001.101or1001.201.

5.Anyfelonyormisdemeanorconviction,underFederalorStatelaw,relatingtotheunlawfulmanufacture,distribution,prescription,ordispensingofacontrolledsubstance.

Exclusions, revocations, or Suspensions1. AnyrevocationorsuspensionofalicensetoprovidehealthcarebyanyStatelicensingauthority. Thisincludesthesurrenderofsuchalicensewhileaformaldisciplinaryproceedingwaspending beforeaStatelicensingauthority.

2.Anyrevocationorsuspensionofaccreditation. 3. Anysuspensionorexclusionfromparticipationin,oranysanctionimposedby,aFederalorStatehealthcareprogram,oranydebarmentfromparticipationinanyFederalExecutiveBranch procurementornon-procurementprogram.

4.AnycurrentMedicarepaymentsuspensionunderanyMedicarebillingnumber. 5.AnyMedicarerevocationofanyMedicarebillingnumber.

CMS-855I (07/11) 12

SECtion 3: final advErSE lEgal aCtionS/ConviCtionS (Continued)

final advErSE lEgal aCtion hiStory1. Haveyou,underanycurrentorformernameorbusinessidentity,everhadafinaladverselegalaction

listed onpage12ofthisapplicationimposedagainstyou?

NO–SkiptoSection4 YES–ContinueBelow

2. Ifyes,reporteachfinaladverselegalaction,whenitoccurred,theFederalorStateagencyorthe court/administrativebodythatimposedtheaction,andtheresolution,ifany. Attachacopyofthefinaladverselegalactiondocumentationandresolution.

final advErSE lEgal aCtion datE taKEn by rESolution

CMS-855I (07/11) 13

SECtion 4: PraCtiCE loCation inforMation

a. Establishing a Professional Corporation, Professional association, limited liability Company, etc. Ifyouarethesoleownerofaprofessionalcorporation,aprofessionalassociation,oralimitedliabilitycompany,andwillbillMedicarethroughthisbusinessentity,completethissection4A,skiptoSection4C,andcompletetheremainderoftheapplicationwithinformationaboutyourbusinessentity. Legal Business Name as Reported to the Internal Revenue Service Tax Identification Number

Medicare Identification Number (if issued) NPI

Incorporation Date (mm/dd/yyyy) (if applicable) State Where Incorporated (if applicable)

Is this supplier an Indian Health Facility enrolling with the designated Indian Health Services (IHS) Medicare Administrative Contractor (MAC)?

NoYes Identify the type of organizational structure of this provider/supplier (Check one)

Other (Specify): ____________Sole ProprietorPartnershipLimited Liability CompanyCorporation

Identify how your business is registered with the IRS. (notE: If your business is a Federal and/or State government provider or supplier, indicate “Non-Profit” below.)

Proprietary Non-Profit

notE: If a checkbox indicating Proprietaryship or non-profit status is not completed, the provider/supplier will be defaulted to “Proprietary.”

final advErSE lEgal aCtion hiStory1. Hasyourorganization,underanycurrentorformernameorbusinessidentity,everhadanyofthe finaladverselegalactionslistedonpage12ofthisapplicationimposedagainstit?

NO–SkiptoSection4B YES–ContinueBelow

2. Ifyes,reporteachfinaladverselegalaction,whenitoccurred,theFederalorStateagencyorthecourt/administrativebodythatimposedtheaction,andtheresolution,ifany. Attachacopyofthefinaladverselegalactiondocumentationandresolution.


If you are the sole owner of a professional corporation, a professional association, or a limitedliability company, and will bill Medicare through this business entity, you do not need to complete a CMS-855R that reassigns your benefits to the business entity.

b. individual affiliations Completethissectionwithinformationaboutyourprivatepracticeandgroupaffiliations. Furnishtherequestedinformationabouteachgroup/organizationtowhichyouwillreassignyourbenefits.Inaddition,eitheryouoreachgroup/organizationreportedinthissectionmustcompleteandsubmitaCMS855R(s)(IndividualReassignmentofBenefits)withthisapplication.Reassigningbenefitsmeansthatyouareauthorizingthegroup/organizationtobillandreceivepaymentfromMedicarefortheservicesyouhaverenderedatthegroup/organization’spracticelocation. Ifyouareanindividualwhoisreassigningallofyourbenefitstoagroup,neitheryounorthegroupneedstosubmitaCMS-588(ElectronicFundsTransferAuthorizationAgreement)tofacilitatethatreassignment. CMS-855I (07/11) 14

SECtion 4: PraCtiCE loCation inforMation (Continued)

1. Ifyouarereassigningallofyourpaymentstoanothergroupororganizationfurnishthename,Medicareidentificationnumber(s)andNPIofeachgroupororganizationbelowandproceedtoSection13.

2. IfanyofyourpaymentsarepartofyourprivatepracticeandagroupororganizationfurnishthenameandMedicareidentificationnumber(s)andNPIofeachgroupororganizationbelowandcontinuetoSection4C(whereyouwillenteryourprivatepracticeinformation).

3. Ifyouarenotreassigningalloranyofyourpaymentstoanothergroupororganization,skipto Section4Cwithinformationaboutyourprivatepractice.

a) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier

b) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier

c) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier

d) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier

e) Name of Group/Organization Medicare Identification Number (if issued) National Provider Identifier

C. Practice location information • IfyoucompletedSection4A,completeSection4CthroughSection17foryourbusiness. • Alllocationsdisclosedonclaimsformsshouldbeidentifiedinthissectionaspracticelocations. • CompletethissectionforeachofyourpracticelocationswhereyourenderservicestoMedicarebeneficiaries.

However,youshouldonlyreportthosepracticelocationswithinthejurisdictionoftheMedicarefee-for-servicecontractortowhichyouwillsubmitthisapplication.Ifyourenderservicesinahospitaland/orotherhealthcarefacility,furnishthenameandaddressofthathospitalorfacility.

• EachpracticelocationmustbeaspecificstreetaddressasrecordedbytheUnitedStatesPostal Service.DonotreportaP.O.Box.

• Ifyouonlyrenderservicesinpatients’homes(housecalls),youmaysupplyyourhomeaddressinthissectionifyoudonothaveanoffice.InSection4H,explainthatthisaddressisforadministrativepurposesonlyandthatallservicesarerenderedinpatients’homes.

• Ifyourenderservicesinaretirementorassistedlivingcommunity,completethissectionwiththe names,telephonenumbersandaddressesofthosecommunities.

IfyouhaveaCLIAnumberand/orFDA/RadiologyCertificationNumberforthispracticelocation,providethatinformationandsubmitacopyofthemostcurrentCLIAandFDAcertificationforeachpracticelocationreported.

CMS-855I (07/11) 15


Ifyouoryourorganizationseespatientsinmorethanonepracticelocation,copyandcompletethisSection4Cforeachlocation.

ChECK onE ChangE add dElEtE

datE (mm/dd/yyyy)

Ifyouarechanging,adding,ordeletinginformation,checktheapplicablebox,furnishtheeffectivedate,andcompletetheappropriatefieldsinthissection.

if you are enrolling for the first time, or if you are adding a new practice location, the date you provide should be the date you saw your first Medicare patient at this location.

Practice Location Name (“Doing Business As” name if different from Legal Business Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Street Address Line 2 (Suite, Room, etc.)



Medicare Identification Number (if issued) NPI

Date you saw your first Medicare patient at this practice location (mm/dd/yyyy)

Is this practice location a:

Hospital Group practice office/clinic

Retirement/assisted living community Other health care facility Skilled Nursing Facility and/or Nursing Facility

(Specify):______________________________

CLIA Number for this location (if applicable) FDA/Radiology (Mammography) Certification Number for this location (if issued)

CMS-855I (07/11) 16


d. rendering Services in Patients’ homesListthecity/town,State,andZIPcodeforalllocationswherehealthcareservicesarerenderedinpatients’homes.IfyouprovidehealthcareservicesinmorethanoneStateandthoseStatesareservicedbydifferentMedicarefee-for-servicecontractors,completeaseparateenrollmentapplication(CMS-855I)foreachMedicarefee-for-servicecontractor’sjurisdiction. Ifyouarechanging,adding,ordeletinginformation,checktheapplicablebox,furnishtheeffectivedate,andcompletetheappropriatefieldsinthissection.


datE (mm/dd/yyyy)

initial rEPorting and/or additionSIfyouarereportingoraddinganentireState,itisnotnecessarytoreporteachcity/town.SimplychecktheboxbelowandspecifytheState. EntireStateof__________________________ Ifservicesareprovidedinselectedcities/towns,providethelocationsbelow.OnlylistZIPcodesifyouarenotservicingtheentirecity/town.

City/town StatE ZiP CodE

dElEtionS IfyouaredeletinganentireState,itisnotnecessarytoreporteachcity/town.SimplychecktheboxbelowandspecifytheState. EntireStateof__________________________ Ifservicesareprovidedinselectedcities/towns,providethelocationsbelow.OnlylistZIPcodesifyouarenotservicingtheentirecity/town.

City/town StatE ZiP CodE

CMS-855I (07/11) 17


E. where do you want remittance notices or Special Payments Sent?Ifyouarechanging,adding,ordeletinginformation,checktheapplicablebox,furnishtheeffectivedate,andcompletetheappropriatefieldsinthissection.


datE (mm/dd/yyyy)

Medicare will issue payments via electronic funds transfer (EFT). SincepaymentwillbemadebyEFT,the“SpecialPayments”addresswillindicatewhereallotherpaymentinformation(e.g.,remittancenotices,specialpayments)aresent. “SpecialPayments”addressisthesameasthepracticelocation(onlyoneaddressislistedin

Section4C).SkiptoSection4F. “SpecialPayments”addressisdifferentthanthatlistedinSection4C,ormultiplelocationsarelisted.

Provideaddressbelow. Furnishtheaddresswhereremittancenoticesandspecialpaymentsshouldbesentforservicesrenderedatthepracticelocation(s)inSection4C.Notethatpaymentswillbemadeinyourname;ifanentityislistedinSection4Aofthisapplication,paymentswillbemadeintheorganization’sname.

“Special Payment” Address Line 1 (PO Box or Street Name and Number)

“Special Payment” Address Line 2 (Suite, Room, etc.)


f. Employer id number information notE: IfyouareasoleproprietorandyouwantMedicarepaymentstobereportedunderyourEIN,listitbelow.Unlessindicatedinthissection,paymentswillbemadetoyourSSN.YoucannotusebothanSSNandEIN.YoucanonlyuseoneEINtobillMedicare. Toqualifyforthispaymentarrangement,you:• Mustbeasoleproprietor, • CannotreassignallofyourMedicarepayments,and, • WantyourpaymentstobemadetoyourEIN.FurnishIRSdocumentationshowingyourEIN.

Employer Identification Number (EIN)

CMS-855I (07/11) 18


g. where do you Keep Patients’ Medical records?Ifthepatients’medicalrecordsarestoredatalocationotherthanthelocationshowninSection4C,completethissectionwiththenameandaddressofthestoragelocation.Thisincludesbothcurrentandformerpatients’records. PostOfficeBoxesanddropboxesarenotacceptableasphysicaladdresseswherepatients’recordsaremaintained.Therecordsmustbeyourrecords,notthoseofanothersupplier.Ifthissectionisnotcompleted,youareindicatingthatallrecordsarestoredatthepracticelocationsreportedinSection4C. Ifyouarechanging,adding,ordeletinginformation,checktheapplicablebox,furnishtheeffectivedate,andcompletetheappropriatefieldsinthissection.

first Medical record Storage facility (for current and former patients)


datE (mm/dd/yyyy)

Storage Facility Address Line 1 (Street Name and Number)

Storage Facility Address Line 2 (Suite, Room, etc.)


Second Medical record Storage facility (for current and former patients)


datE (mm/dd/yyyy)

Storage Facility Address Line 1 (Street Name and Number)

Storage Facility Address Line 2 (Suite, Room, etc.)


h. unique CircumstancesExplainanyuniquecircumstancesconcerningyourpracticelocationsorthemethodbywhichyourenderhealthcareservices(e.g.,youonlyrenderservicesinpatients’homes[housecallsonly]).

SECtion 5: for futurE uSE (thiS SECtion not aPPliCablE)

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SECtion 6: individualS having Managing Control

Thissectioncapturesinformationaboutallmanagingemployees.Amanagingemployeemeansageneralmanager,businessmanager,administrator,director,orotherindividualwhoexercisesoperationalormanagerialcontrolover,orwhodirectlyorindirectlyconducts,theday-to-dayoperationsofthesupplier,eitherundercontractorthroughsomeotherarrangement,regardlessofwhethertheindividualisaW-2employeeofthesupplier. AllmanagingemployeesatanyofyourpracticelocationsshowninSection4mustbereportedinthissection.Ifthereismorethanonemanagingemployee,copyandcompletethissectionasneeded.

a. Managing Employee identifying information Ifyouarechanging,adding,ordeletinginformation,checktheapplicablebox,furnishtheeffectivedate,andcompletetheappropriatefieldsinthissection.


datE (mm/dd/yyyy)

First Name Middle Initial Last Name Jr., Sr., etc. Title

Medicare Identification Number (if issued) NPI (if issued)

Social Security Number (Required) Date of Birth (mm/dd/yyyy) Place of Birth (State) Country of Birth

What is the effective date this individual acquired managing control of the provider identified in Section 2A of this application? (mm/dd/yyyy)

b. final adverse legal action history CompletethissectionfortheindividualreportedinSection6Aabove.Ifyouarechangingoraddinginformation,checkthe“change”box,furnishtheeffectivedate,andcompletetheappropriatefieldsinthissection.

EffectiveDate:______________________ Change

1. HasthisindividualinSection6Aabove,underanycurrentorformernameorbusinessidentity,everhadafinaladverselegalactionlistedonpage12ofthisapplicationimposedagainsthim/her?

NO–SkiptoSection8 YES–ContinueBelow

2. Ifyes,reporteachfinaladverselegalaction,whenitoccurred,theFederalorStateagencyorthecourt/administrativebodythatimposedtheaction,andtheresolution,ifany. Attachacopyofthefinaladverselegalactiondocumentationandresolution.


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SECtion 8: billing agEnCy inforMa tion

Abillingagencyisacompanyorindividualthatyoucontractwithtoprepareandsubmityourclaims.Ifyouuseabillingagency,youareresponsiblefortheclaimssubmittedonyourbehalf.

ChECK hErE if this section does not apply and skip to Section 13.

Ifyouarechanging,adding,ordeletinginformation,checktheapplicableboxandfurnishtheeffectivedate.


datE (mm/dd/yyyy)

billing agency name and address Completetheappropriatefieldsinthissection. Legal Business Name (as Reported to the Internal Revenue Service) If Individual, Billing Agent Date of Birth (mm/dd/yyyy)

“Doing Business As” Name (if applicable) Tax ID Number or Social Security Number (required)

Billing Agency Address Line 1 (Street Name and Number)

Billing Agency Address Line 2 (Suite, Room, etc.)







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SECtion 13: ContaCt PErSon

Thissectioncapturesinformationregardingthepersonyouwouldlikeforustocontactregardingthisapplication.Ifnooneislistedbelow,wewillcontactyoudirectly.

First Name Middle Initial Last Name Jr., Sr., etc.


Address Line 1 (Street Name and Number)

Address Line 2 (Suite, Room, etc.)


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SECtion 14: PEnaltiES for f alSifying inforMa tion this section explains the penalties for deliberately furnishing false information in this application to gain or maintain enrollment in the Medicare program.

1. 1.18U.S.C.§1001authorizescriminalpenaltiesagainstanindividualwho,inanymatterwithinthejurisdictionofanydepartmentoragencyoftheUnitedStates,knowinglyandwillfullyfalsifies,concealsorcoversupbyanytrick,schemeordeviceamaterialfact,ormakesanyfalse,fictitious,orfraudulentstatementsorrepresentations,ormakesanyfalsewritingordocumentknowingthesametocontainanyfalse,fictitiousorfraudulentstatementorentry.Individualoffendersaresubjecttofinesofupto$250,000andimprisonmentforuptofiveyears.Offendersthatareorganizationsaresubjecttofinesofupto$500,000(18U.S.C.§3571).Section3571(d)alsoauthorizesfinesofuptotwicethegrossgainderivedbytheoffenderifitisgreaterthantheamountspecificallyauthorizedbythesentencingstatute.

2. Section1128B(a)(1)oftheSocialSecurityActauthorizescriminalpenaltiesagainstanyindividualwho,“knowinglyandwillfully,”makesorcausestobemadeanyfalsestatementorrepresentationofamaterialfactinanyapplicationforanybenefitorpaymentunderaFederalhealthcareprogram.Theoffenderissubjecttofinesofupto$25,000and/orimprisonmentforuptofiveyears.

3. TheCivilFalseClaimsAct,31U.S.C.§3729,imposescivilliability,inpart,onanypersonwho:a) knowinglypresents,orcausestobepresented,toanofficeroranyemployeeoftheUnited StatesGovernmentafalseorfraudulentclaimforpaymentorapproval;

b) knowinglymakes,uses,orcausestobemadeorused,afalserecordorstatementtogetafalseorfraudulentclaimpaidorapprovedbytheGovernment;or

c) conspirestodefraudtheGovernmentbygettingafalseorfraudulentclaimallowedorpaid. TheActimposesacivilpenaltyof$5,000to$10,000perviolation,plusthreetimestheamountofdamagessustainedbytheGovernment

4. Section1128A(a)(1)oftheSocialSecurityActimposescivilliability,inpart,onanyperson(includinganorganization,agencyorotherentity)thatknowinglypresentsorcausestobepresentedtoanofficer,employee,oragentoftheUnitedStates,orofanydepartmentoragencythereof,orofanyStateagency…aclaim…thattheSecretarydeterminesisforamedicalorotheritemorservicethatthepersonknowsorshouldknow:a) wasnotprovidedasclaimed;and/orb) theclaimisfalseorfraudulent. Thisprovisionauthorizesacivilmonetarypenaltyofupto$10,000foreachitemorservice,anassessmentofuptothreetimestheamountclaimed,andexclusionfromparticipationintheMedicareprogramandStatehealthcareprograms.

5. 18U.S.C.1035authorizescriminalpenaltiesagainstindividualsinanymatterinvolvingahealthcarebenefitprogramwhoknowinglyandwillfullyfalsifies,concealsorcoversupbyanytrick,scheme,ordeviceamaterialfact;ormakesanymateriallyfalse,fictitious,orfraudulentstatementsorrepresentations,ormakesorusesanymateriallyfalsefictitious,orfraudulentstatementorentry,inconnectionwiththedeliveryoforpaymentforhealthcarebenefits,itemsorservices.Theindividualshallbefinedorimprisonedupto5yearsorboth.

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SECtion 14: PEnaltiES for f alSifying inforMa tion (Continued)

6. 18U.S.C.1347authorizescriminalpenaltiesagainstindividualswhoknowingandwillfullyexecute,orattempt,toexecutiveaschemeorartificetodefraudanyhealthcarebenefitprogram,ortoobtain,bymeansoffalseorfraudulentpretenses,representations,orpromises,anyofthemoneyorpropertyownedbyorunderthecontrolofany,healthcarebenefitprograminconnectionwiththedeliveryoforpaymentforhealthcarebenefits,items,orservices.Individualsshallbefinedorimprisonedupto10yearsorboth.Iftheviolationresultsinseriousbodilyinjury,anindividualwillbefinedorimprisoned upto20years,orboth.Iftheviolationresultsindeath,theindividualshallbefinedorimprisonedforanytermofyearsorforlife,orboth.

7. Thegovernmentmayassertcommonlawclaimssuchas“commonlawfraud,”“moneypaidbymistake,”and“unjustenrichment.” Remediesincludecompensatoryandpunitivedamages,restitution,andrecoveryoftheamountoftheunjustprofit.

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SECtion 15: CErtifiCation StatEMEnt (Continued)

Asanindividualpractitioner,youaretheonlypersonwhocansignthisapplication.Theauthoritytosigntheapplicationonyourbehalfmaynotbedelegatedtoanyotherperson. TheCertificationStatementcontainscertainstandardsthatmustbemetforinitialandcontinuous enrollmentintheMedicareprogram.Reviewtheserequirementscarefully. BysigningtheCertificationStatement,youagreetoadheretoalloftherequirementslistedthereinandacknowledgethatyoumaybedeniedentrytoorrevokedfromtheMedicareprogramifanyrequirementsarenotmet.

Certification Statement

YouMUSTsignanddatethecertificationstatementbelowinordertobeenrolledintheMedicareprogram.Indoingso,youareattestingtomeetingandmaintainingtheMedicarerequirementsstatedbelow. I, the undersigned, certify to the following:1.Ihavereadthecontentsofthisapplication,andtheinformationcontainedhereinistrue,correct,andcomplete.IfIbecomeawarethatanyinformationinthisapplicationisnottrue,correct,orcomplete,IagreetonotifytheMedicarefee-for-servicecontractorofthisfactinaccordancewiththetimeframesestablishedin42CFR§424.516.

2.IauthorizetheMedicarecontractortoverifytheinformationcontainedherein.IagreetonotifytheMedicarecontractorofachangeinownership,practicelocationand/orFinalAdverseActionwithin30daysofthereportableevent.Inaddition,IagreetonotifytheMedicarecontractorofanyotherchangestotheinformationtothisformwithin90daysoftheeffectivedateofchange.Iunderstandthatanychangetomystatusasanindividualpractitionermayrequirethesubmissionofanewapplication.Iunderstandthatanychangeinbusinessstructureofthissuppliermayrequirethesubmissionofanewapplication.

3.IhavereadandunderstandthePenaltiesforFalsifyingInformation,asprintedinthisapplication.Iunderstandthatanydeliberateomission,misrepresentation,orfalsificationofanyinformationcontainedinthisapplicationorcontainedinanycommunicationsupplyinginformationtoMedicare,oranydeliberatealterationofanytextonthisapplicationform,maybepunishedbycriminal,civil,oradministrativepenaltiesincluding,butnotlimitedto,thedenialorrevocationofMedicarebillingprivileges,and/ortheimpositionoffines,civildamages,and/orimprisonment.

4.IagreetoabidebytheMedicarelaws,regulationsandprograminstructionsthatapplytomeortotheorganizationlistedinSection4Aofthisapplication.TheMedicarelaws,regulations,andprograminstructionsareavailablethroughthefee-for-servicecontractor.IunderstandthatpaymentofaclaimbyMedicareisconditionedupontheclaimandtheunderlyingtransactioncomplyingwithsuchlaws,regulations,andprograminstructions(including,butnotlimitedto,theFederalanti-kickbackstatuteandtheStarklaw),andonthesupplier’scompliancewithallapplicableconditionsofparticipationinMedicare.

5.NeitherI,noranymanagingemployeelistedonthisapplication,iscurrentlysanctioned,suspended,debarred,orexcludedbytheMedicareorStateHealthCareProgram,e.g.,Medicaidprogram,oranyotherFederalprogram,orisotherwiseprohibitedfromprovidingservicestoMedicareorotherFederalprogrambeneficiaries.

6.Iagreethatanyexistingorfutureoverpaymentmadetome(ortotheorganizationlistedinSection4Aofthisapplication)bytheMedicareprogrammayberecoupedbyMedicarethroughthewithholdingoffuturepayments.

7.IunderstandthattheMedicareidentificationnumberissuedtomecanonlybeusedbymeorbyaproviderorsuppliertowhomIhavereassignedmybenefitsundercurrentMedicareregulations,whenbillingforservicesrenderedbyme.

8.IwillnotknowinglypresentorcausetobepresentedafalseorfraudulentclaimforpaymentbyMedicare,andwillnotsubmitclaimswithdeliberateignoranceorrecklessdisregardoftheirtruthorfalsity.

9.IfurthercertifythatIamtheindividualpractitionerwhoisapplyingforMedicarebillingprivileges. CMS-855I (07/11) 25

SECtion 15: CErtifiCation StatEMEnt (Continued)

First Name Middle Initial Last Name M.D., D.O., etc.

Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.) Date Signed (mm/dd/yyyy)

all signatures must be original and signed in ink (blue ink preferred). applications with signatures deemed not original will not be processed. Stamped, faxed or copied signatures will not be accepted.


SECtion 17: SuPPorting doCuMEntS

This section lists the documents that, if applicable, must be submitted with this enrollmentapplication. For changes, only submit documents that are applicable to the change requested. Thefee-for-service contractor may request, at any time during the enrollment process, documentation tosupport or validate information reported on the application. In addition, the Medicare fee-for-servicecontractor may also request documents from you, other than those identified in this section 17, as arenecessary to bill Medicare. Mandatory for all ProvidEr/SuPPliEr tyPES CompletedFormCMS-588,forElectronicFundsTransferAuthorizationAgreement. notE:Ifasupplieralreadyreceivespaymentselectronicallyandisnotmakingachangetohis/her bankinginformation,theCMS-588isnotrequired.(Moreover,physiciansandnon-physicianpractitionerswhoarereassigningalloftheirpaymentstoanotherentityarenotrequiredtosubmittheCMS-588.)WrittenconfirmationfromtheIRSconfirmingyourTaxIdentificationNumberwiththeLegalBusinessName(e.g.,IRSformCP575)providedinSection2.(notE:Thisinformationisneedediftheapplicantisenrollingtheirprofessionalcorporation,professionalassociation,orlimitedliabilitycorporationwiththis application or enrolling as a sole proprietorusinganEmployerIdentificationNumber.)

Mandatory, if aPPliCablECopyofIRSDeterminationLetter,ifproviderisregisteredwiththeIRSasnon-profit.Copy(s)ofallfinaladverseactiondocumentation(e.g.,notifications,resolutions,andreinstatementletters).CompletedFormCMS-460,MedicareParticipatingPhysicianorSupplierAgreement.CompletedFormCMS-855R,IndividualReassignmentofMedicareBenefits.Statementinwritingfromthebank.IfMedicarepaymentdueasupplierofservicesisbeingsenttoabank(orsimilarfinancialinstitution)wherethesupplierhasalendingrelationship(thatis,anytypeofloan),thenthesuppliermustprovideastatementinwritingfromthebank(whichmustbeintheloanagreement)thatthebankhasagreedtowaiveitsrightofoffsetforMedicarereceivables.WrittenconfirmationfromtheIRSconfirmingyourLimitedLiabilityCompany(LLC)isautomaticallyclassifiedasaDisregardedEntity(e.g.,Form8832).(notE:Adisregardedentityisaneligibleentitythatistreatedasanentitynotseparatefromitssingleownerforincometaxpurposes.)CopyofcurrentCLIAandFDAcertificationforeachpracticelocationreported.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. do not Mail aPPliCationS to thiS addrESS. Mailing your application to this address will significantly delay application processing.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES

MEdiCarE SuPPliEr EnrollMEnt aPPliCation PrivaCy aCt StatEMEnt

TheCentersforMedicare&MedicaidServices(CMS)isauthorizedtocollecttheinformationrequestedonthisformbysections1124(a)(1),1124A(a)(3),1128,1814,1815,1833(e),and1842(r)oftheSocialSecurityAct[42U.S.C.§§1320a-3(a)(1),1320a-7,1395f,1395g,1395(l)(e),and1395u(r)]andsection31001(1)oftheDebtCollectionImprovementAct[31U.S.C.§7701(c)]. ThepurposeofcollectingthisinformationistodetermineorverifytheeligibilityofindividualsandorganizationstoenrollintheMedicareprogramassuppliersofgoodsandservicestoMedicarebeneficiariesandtoassistintheadministrationoftheMedicareprogram.ThisinformationwillalsobeusedtoensurethatnopaymentswillbemadetoproviderswhoareexcludedfromparticipationintheMedicareprogram.Allinformationonthisformisrequired,withtheexceptionofthosesectionsmarkedas“optional”ontheform.Withoutthisinformation,theabilitytomakepaymentswillbedelayedordenied. TheinformationcollectedwillbeenteredintotheProviderEnrollment,ChainandOwnershipSystem(PECOS).Theinformationinthisapplicationwillbedisclosedaccordingtotheroutineusesdescribedbelow. Informationfromthesesystemsmaybedisclosedunderspecificcircumstancesto:1. CMScontractorstocarryoutMedicarefunctions,collatingoranalyzingdata,ortodetectfraudorabuse;2. Acongressionalofficefromtherecordofanindividualhealthcareproviderinresponsetoaninquiryfromthecongressionalofficeatthewrittenrequestofthatindividualhealthcarepractitioner;

3. TheRailroadRetirementBoardtoadministerprovisionsoftheRailroadRetirementorSocialSecurityActs;4. PeerReviewOrganizationsinconnectionwiththereviewofclaims,orinconnectionwithstudiesorotherreviewactivities,conductedpursuanttoPartBofTitleXVIIIoftheSocialSecurityAct;

5. TotheDepartmentofJusticeoranadjudicativebodywhentheagency,anagencyemployee,ortheUnitedStatesGovernmentisapartytolitigationandtheuseoftheinformationiscompatiblewiththepurposeforwhichtheagencycollectedtheinformation;

6. TotheDepartmentofJusticeforinvestigatingandprosecutingviolationsoftheSocialSecurityAct,towhichcriminalpenaltiesareattached;

7. TotheAmericanMedicalAssociation(AMA),forthepurposeofattemptingtoidentifymedicaldoctorswhentheNationalPlanandProviderEnumerationSystemisunabletoestablishidentityaftermatchingcontractorsubmitteddatatothedataextractprovidedbytheAMA;

8. Anindividualororganizationforaresearch,evaluation,orepidemiologicalprojectrelatedtothepreventionofdiseaseordisability,ortotherestorationormaintenanceofhealth;

9. OtherFederalagenciesthatadministeraFederalhealthcarebenefitprogramtoenumerate/enrollprovidersofmedicalservicesortodetectfraudorabuse;

10. StateLicensingBoardsforreviewofunethicalpracticesornon-professionalconduct;11. Statesforthepurposeofadministrationofhealthcareprograms;and/or 12. Insurancecompanies,selfinsurers,healthmaintenanceorganizations,multipleemployertrusts,andotherhealthcaregroupsprovidinghealthcareclaimsprocessing,whenalinktoMedicareorMedicaidclaimsisestablished,anddataareusedsolelytoprocesssupplier’shealthcareclaims.

ThesuppliershouldbeawarethattheComputerMatchingandPrivacyProtectionActof1988(P.L.100-503)amendedthePrivacyAct,5U.S.C.§552a,topermitthegovernmenttoverifyinformationthroughcomputermatching.

Protection of Proprietary informationPrivilegedorconfidentialcommercialorfinancialinformationcollectedinthisformisprotectedfrompublicdisclosurebyFederallaw5U.S.C.§552(b)(4)andExecutiveOrder12600.

Protection of Confidential Commercial and/or Sensitive Personal informationIfanyinformationwithinthisapplication(orattachmentsthereto)constitutesatradesecretorprivilegedorconfidentialinformation(assuchtermsareinterpretedundertheFreedomofInformationActandapplicablecaselaw),orisofahighlysensitivepersonalnaturesuchthatdisclosurewouldconstituteaclearlyunwarrantedinvasionofthepersonalprivacyofoneormorepersons,thensuchinformationwillbeprotectedfromreleasebyCMSunder5U.S.C.§§552(b)(4)and/or(b)(6),respectively.

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