Form CMS-460, Medicare Participation Agreement Instructions
This form contains 11 fields organized into 5 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Agreement Details | ||
| Effective Date 1 | Text |
Enter the effective date of the agreement when the provider or supplier starts accepting Medicare Part B payments.
|
| Date | Text |
Enter the date when the form is being filled out.
|
| Effective Date | Text |
Enter the effective date of the agreement when the provider or supplier starts accepting Medicare Part B payments.
|
| Carrier Information | ||
| Received by (name of carrier) | Text |
Enter the name of the carrier who received the form.
|
| Initials of Carrier Official | Text |
Enter the initials of the carrier official who received the form.
|
| Contact Information | ||
| Office Phone Number (including area code) | Text |
Enter the office phone number of the healthcare provider or supplier, including the area code.
|
| Participant Information | ||
| Name and Address of Participant | Text |
Enter the full name and address of the healthcare provider or supplier participating in the Medicare program.
|
| Name and Address of Participant | Text |
Enter the full name and address of the healthcare provider or supplier participating in the Medicare program.
|
| Name and Address of Participant | Text |
Enter the full name and address of the healthcare provider or supplier participating in the Medicare program.
|
| National Provider Identifier (NPI) | Text |
Enter the National Provider Identifier (NPI) of the healthcare provider or supplier.
|
| Signatory Information | ||
| Title (if signer is authorized representative of organization) | Text |
If the signer is an authorized representative of the organization, enter their title.
|