CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners Completed Form Examples and Samples

Explore real-world CMS-855I Medicare Enrollment Application examples and samples for physicians and non-physician practitioners. See how AI automatically fills out CMS-855I forms using provider credentials, NPI numbers, specialty codes, license details, and practice information — saving time and reducing enrollment errors.

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Completed CMS-855I Medicare Enrollment Application for an internal medicine physician enrolling as a new Medicare provider

CMS-855I Example – New Medicare Enrollment for an Internal Medicine Physician

How this form was filled:

Our AI extracted the physician's credentials, practice details, and personal information from a medical practice administrator's onboarding memo and automatically filled the CMS-855I Medicare Enrollment Application. The AI correctly identified the enrollment reason, mapped license and DEA registration numbers, placed the practice address into the appropriate fields, and determined the correct physician specialty — all from a single unstructured document.

Source document used: Medical Practice Administrator Onboarding Memo

INTERNAL MEMO
TO: Medicare Enrollment Team
FROM: Sandra Whitfield, Practice Administrator
RE: New Provider Enrollment – Dr. Margaret Thornton
DATE: February 4, 2026

Hi team,

Please begin the Medicare enrollment process for our newest physician, Dr. Margaret Ann Thornton, M.D., who joined Lakeside Medical Group on January 20th. She has never previously been enrolled in Medicare and will need to be set up as a brand new enrollee. Her date of birth is June 14, 1981, and her Social Security Number is 312-55-7894.

Dr. Thornton completed her medical degree at the University of Colorado School of Medicine in 2008 and her primary specialty is Internal Medicine. She does not practice acupuncture and does not have secondary specialties at this time. She is currently accepting new Medicare patients.

For her credentials: her active Colorado medical license number is CO-78432, which was issued effective March 1, 2014, and is not a compact license. She is board certified through the American Board of Internal Medicine; her certification number is ABIM-204891 with an effective date of June 15, 2009. Her DEA registration number is BT4421983, effective January 1, 2024, issued in Colorado.

Dr. Thornton's National Provider Identifier (NPI) is 1982736450. She is operating as a sole proprietor under her own SSN (not an EIN), and her private practice will be at Lakeside Medical Group, located at 4820 Cherry Creek Drive South, Suite 310, Denver, CO 80246. The main telephone number there is 303-555-0172 and fax is 303-555-0198. Her first Medicare patient appointment is scheduled for February 10, 2026. This is her primary practice location and it is a private office setting. All medical records will be stored at the practice location.

For correspondence and remittance notices, please use the same practice address. Medical record correspondence should also go to the practice address. She does not use a billing agency — she will handle billing in-house. She is the managing employee of her own practice.

Her email for enrollment correspondence is [email protected]. No prior adverse legal actions of any kind.

Please also note that Dr. Thornton would like to be a participating Medicare provider, so include the CMS-460 with the enrollment package. EFT setup will be needed, so include the CMS-588 as well.

Let me know if you have any questions.

Sandra Whitfield
Practice Administrator, Lakeside Medical Group
303-555-0100

Information used to fill out the document:

Provider Name & DOB: Dr. Margaret Ann Thornton, M.D. — DOB: June 14, 1981
SSN & NPI: SSN: 312-55-7894 | NPI (Type 1): 1982736450
Medical School & Graduation: University of Colorado School of Medicine, 2008
Primary Specialty: Internal Medicine (Primary)
License, Certification & DEA: CO License CO-78432 (eff. 03/01/2014) | ABIM Cert ABIM-204891 (eff. 06/15/2009) | DEA BT4421983 (eff. 01/01/2024), Colorado
Practice Address: 4820 Cherry Creek Drive South, Suite 310, Denver, CO 80246 | Tel: 303-555-0172
Business Structure: Sole Proprietor under SSN, Private Office Setting
Enrollment Reason: New enrollee in Medicare
Adverse Legal Actions: None
Supporting Documents: CMS-460 (Participating Provider) and CMS-588 (EFT) required

What this filled form sample shows:

Identified new Medicare enrollment as the reason for submission from the phrase 'never previously been enrolled in Medicare'
Extracted license, board certification, and DEA registration numbers with their respective effective dates and issuing states from a dense paragraph
Correctly mapped Internal Medicine as the primary physician specialty from conversational memo text
Parsed the sole proprietor/SSN payment arrangement from the phrase 'operating as a sole proprietor under her own SSN'
Mapped a single practice address to correspondence, medical record, remittance, and practice location address fields
Inferred managing employee self-designation from the statement that Dr. Thornton handles billing in-house
Flagged the need for CMS-460 and CMS-588 supporting documents from the administrator's note about participating provider status and EFT setup

Form specifications and details:

Use Case:	New Medicare enrollment for an internal medicine physician in a sole proprietor private practice
Source Document:	Medical practice administrator's internal onboarding memo
Enrollment Type:	New Enrollee in Medicare
Physician Specialty:	Internal Medicine (Primary)
Business Structure:	Sole Proprietor, billed under SSN
Practice Location Type:	Private Office Setting
Adverse Legal Actions:	None reported
Supporting Documents Required:	CMS-460, CMS-588 with voided check
Categories:	CAR forms, healthcare provider forms, practitioner forms, CMS forms, physician forms, enrollment forms, L.A. Care forms, enrollment application forms, Medicare forms
Created:	March 10, 2026 05:56 AM