This form contains 513 fields organized into 114 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Active Certification Information
Active Certification	Checkbox	Check this box if you have an active certification relevant to your primary or secondary specialty. Fill only if 'Practitioner Specific Information' is 'Yes'.
Not Applicable	Checkbox	Check this box if no active certification information is applicable for your primary or secondary specialty. Fill only if 'Practitioner Specific Information' is 'Yes'.
2nd Active Certification Number	Text	Enter the certification number for this active certification. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
2nd Active Certification Effective Date	Date	Provide the effective date of this active certification. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
2nd Active Certification Certifying Entity	Text	Enter the name of the entity that issued this active certification, such as a Specialty Board or State. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
2nd Active Certification State Where Issued	Text	Enter the state where this active certification was issued, or 'all' if certified by a national entity. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
Active License Information
1. Active License	Checkbox	Check this box to indicate that you are providing information for an active license. Fill only if 'Practitioner Specific Information' is 'Yes'.
1. Not Applicable	Checkbox	Check this box if the active license information section is not applicable to you. Fill only if 'Practitioner Specific Information' is 'Yes'.
Active License Number	Text	Enter the active license number. Fill only if '1. Active License' is 'Yes'. Depends on: 1. Active License
Active License Effective Date	Date	Enter the effective date of the active license. Fill only if '1. Active License' is 'Yes'. Depends on: 1. Active License
Active License State Where Issued	Text	Enter the state where the active license was issued. Fill only if '1. Active License' is 'Yes'. Depends on: 1. Active License
Compact License Yes	Checkbox	Check this box if your license is a compact license. Fill only if '1. Active License' is 'Yes'. Depends on: 1. Active License
Compact License No	Checkbox	Check this box if your license is not a compact license. Fill only if '1. Active License' is 'Yes'. Depends on: 1. Active License
Acupuncture Services Provision Question
1. Does the physician identitied in section 2A provide acupuncture services and meet all state laws and requirements regarding such services? Yes	CheckBox
No	CheckBox
Acupuncture Services Status
Acupuncture Services Status: No	Checkbox	Check this box if the physician assistant, nurse practitioner, or clinical nurse specialist does not provide acupuncture services. Fill only if 'Clinical Nurse Specialist (CNS)', 'Nurse Practitioner', 'Physician Assistant' is checked, any. Depends on: Clinical Nurse Specialist (CNS), Nurse Practitioner, Physician Assistant
Acupuncture Services Status: Yes	Checkbox	Check this box if the physician assistant, nurse practitioner, or clinical nurse specialist provides acupuncture services and meets the degree and licensing requirements mentioned. Fill only if 'Clinical Nurse Specialist (CNS)', 'Nurse Practitioner', 'Physician Assistant' is checked, any. Depends on: Clinical Nurse Specialist (CNS), Nurse Practitioner, Physician Assistant
Address Information Details
Correspondence Mailing Address	CheckBox	Depends on: Address Information
Medical Record Correspondence Mailing Address	CheckBox	Depends on: Address Information
Remittance Notices/Special Payment Mailing Address	CheckBox	Depends on: Address Information
Medicare Beneficiary Medical Records Storage Address	CheckBox	Depends on: Address Information
Practice Location Address	CheckBox	Depends on: Address Information
Adverse Legal Action Documentation
Copy(s) of all final adverse legal action documentation	Checkbox	Check this box if you are submitting copies of all final adverse legal action documentation, such as notifications, resolutions, or reinstatement letters. Fill only if 'Have you, under any current or former name, had a final adverse legal action listed above imposed against you?' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Adverse Legal Action History Confirmation
Adverse Legal Action History Confirmation No	Checkbox	Check this box if you have NOT had a final adverse legal action listed above imposed against you, and you will skip to section 4. Fill only if 'You are voluntarily terminating your Medicare enrollment' is 'No'. Depends on: 7. Voluntarily Terminating Medicare Enrollment
Adverse Legal Action History Confirmation Yes	Checkbox	Check this box if you have had a final adverse legal action listed above imposed against you, and you need to continue to report details below. Fill only if 'You are voluntarily terminating your Medicare enrollment' is 'No'. Depends on: 7. Voluntarily Terminating Medicare Enrollment
Adverse Legal Action History Question
Yes, continue below	Checkbox	Check this box if your business has had a final adverse legal action imposed against it, and you will provide details in part 'b'. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
No, skip to section 4	Checkbox	Check this box if your business has NOT had any final adverse legal action imposed against it, and you can skip to section 4. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
No, skip to section 8	Checkbox	Check this box if the individual has not had a final adverse legal action imposed against them and you wish to skip to section 8. Fill only if 'Reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Yes, continue below	Checkbox	Check this box if the individual has had a final adverse legal action imposed against them and you need to continue to provide details in the subsequent section. Fill only if 'Reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Billing Agency/Agent Contact Information
Billing Agency/Agent Telephone Number	Text	Please enter the telephone number for the billing agency or agent. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent Fax Number	Text	Please enter the fax number for the billing agency or agent, if applicable. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent E-mail Address	Text	Please enter the e-mail address for the billing agency or agent, if applicable. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent Name and Address
Billing Agency/Agent Legal Name	Text	Enter the legal business name as reported to the IRS or the individual's name as reported to the Social Security Administration for the billing agency or agent. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Individual Billing Agent Date of Birth	Date	Provide the date of birth for the individual billing agent. Fill only if 'Section Not Applicable' is 'No' and the agent is an individual. Depends on: Section Not Applicable
Billing Agency/Agent Tax ID/SSN	Text	Enter the required Tax Identification Number for the billing agency or the Social Security Number for the billing agent. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent Doing Business As Name	Text	Provide the 'Doing Business As' name for the billing agency or agent, if applicable. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent Address Line 1	Text	Enter the street name and number for the billing agency or agent's address. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent Address Line 2	Text	Enter any additional address details such as suite, room, or apartment number for the billing agency or agent. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent City/Town	Text	Provide the city or town for the billing agency or agent's address. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent State	Text	Enter the state for the billing agency or agent's address. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Agency/Agent ZIP Code	Text	Enter the ZIP Code, including the +4 extension, for the billing agency or agent's address. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Billing Rights
Billing Rights No	Checkbox	Check this box if you do not have the right to bill directly, or to collect and retain the fee for your services. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Billing Rights Yes	Checkbox	Check this box if you have the right to bill directly, and to collect and retain the fee for your services. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Business Identification
Legal Business Name	Text	Enter the legal name of your business as it is reported to the Internal Revenue Service. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Tax Identification Number	Text	Enter the Tax Identification Number (TIN) for your business. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Medicare Identification Number (PTAN)	Text	Enter your Medicare Identification Number (Provider Transaction Access Number), if one has been issued. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
NPI (Type 2 - Organization)	Text	Enter the National Provider Identifier (NPI) for your organization (Type 2). Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Business Structure Information
Proprietary	Checkbox	Check this box if your business is registered as Proprietary with the IRS. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Non-Profit	Checkbox	Check this box if your business is registered as Non-Profit and requires submitting IRS Form 501(c)(3). Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Disregarded Entity	Checkbox	Check this box if your business is registered as a Disregarded Entity and requires submitting IRS Form 8832. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
C. NEW PATIENT INFORMATION
New Patient Information - Yes	Checkbox	Check this box if you are currently accepting new Medicare patients.
New Patient Information - No	Checkbox	Check this box if you are not currently accepting new Medicare patients.
Change Information
Change	Checkbox	Check this box if you are updating or changing previously reported information regarding services rendered in patients' homes. Fill only if 'Do you ONLY render PT/OT services in the patients' homes?' is 'Yes'. Depends on: J. Physical/occupational therapist Information. Physical Therapists/Occupational Therapists in Private Practice (P.T./O.T.). 1. Do you ONLY render P.T./O.T. services in the patients’ homes? Yes
Change Effective Date	Date	Provide the effective date for the reported change. Fill only if 'Change' is 'Yes'. Depends on: Change
Change of Remittance Notice/Special Payments Mailing Address
Change	Checkbox	Check this box if you are reporting a change to your Remittance Notice/Special Payments Mailing Address and then furnish the effective date. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No' for all dependency fields. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Change Effective Date	Date	Enter the effective date for the change of remittance notice or special payments mailing address. Fill only if 'Change' is 'Yes'. Depends on: Change
Comments/Special Circumstances
Comments/Special Circumstances	Text	Provide details on any unique circumstances concerning your practice location(s) or the method of rendering health care services. Fill only if 'Do you ONLY render PT/OT services in the patients' homes?' is 'Yes'. Depends on: J. Physical/occupational therapist Information. Physical Therapists/Occupational Therapists in Private Practice (P.T./O.T.). 1. Do you ONLY render P.T./O.T. services in the patients’ homes? Yes
Correspondence Contact Information
Telephone Number (if applicable)	Text
Fax Number (if applicable)	Text
E-mail Address (if applicable)	Text
Correspondence Mailing Address
Attention	Text	Enter the name of the person or department to whose attention the correspondence should be directed. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
Address Line 1	Text	Provide the first line of the correspondence mailing address, which can include a P.O. Box or street name and number. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
Address Line 2	Text	Provide the second line of the correspondence mailing address, such as a suite number, room number, or apartment number. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
City/Town	Text	Enter the city or town for the correspondence mailing address. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
State	Text	Enter the state for the correspondence mailing address. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
ZIP Code + 4	Text	Enter the ZIP code, including the +4 extension, for the correspondence mailing address. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
Correspondence Mailing Address Change
Change	Checkbox	Check this box if you are reporting a change to your Correspondence Mailing Address. Fill only if 'Correspondence Mailing Address' is 'Yes'. Depends on: Correspondence Mailing Address
Correspondence Mailing Address Change Effective Date	Date	Enter the effective date for the correspondence mailing address change. Fill only if 'Change' is checked. Depends on: Change
Date Signed
Date Signed	Date	Provide the date the form was signed.
Delegated Official Date Signed	Date	Enter the date the delegated or authorized official signed this form. Fill only if 'Reassignment of Benefits information in Section 4F' is being accepted, terminated, or changed Depends on: Terminate, Add, Change, Organization/Group Terminate Action, Organization/Group Add Action, Organization/Group Change Action
Delegated or Authorized Official's Printed Name
Delegated Official's First Name	Text	Enter the first name of the delegated or authorized official. Fill only if 'Reassignment of Benefits information in Section 4F' is being accepted, terminated, or changed Depends on: Terminate, Add, Change, Organization/Group Terminate Action, Organization/Group Add Action, Organization/Group Change Action
Delegated Official's Middle Initial	Text	Enter the middle initial of the delegated or authorized official. Fill only if 'Reassignment of Benefits information in Section 4F' is being accepted, terminated, or changed Depends on: Terminate, Add, Change, Organization/Group Terminate Action, Organization/Group Add Action, Organization/Group Change Action
Delegated Official's Last Name	Text	Enter the last name of the delegated or authorized official. Fill only if 'Reassignment of Benefits information in Section 4F' is being accepted, terminated, or changed Depends on: Terminate, Add, Change, Organization/Group Terminate Action, Organization/Group Add Action, Organization/Group Change Action
Delegated Official's Suffix	Text	Enter any applicable suffix for the delegated or authorized official (e.g., Jr., Sr., M.D.). Fill only if 'Reassignment of Benefits information in Section 4F' is being accepted, terminated, or changed Depends on: Terminate, Add, Change, Organization/Group Terminate Action, Organization/Group Add Action, Organization/Group Change Action
Deletion Entire State
Deletion Entire State	Checkbox	Check this box if you are deleting an entire state.
Deletion Entire State	Text	Enter the name of the state that is being entirely deleted. Fill only if 'Deletion Entire State' is 'Yes'. Depends on: Deletion Entire State
Doctoral Psychology Degree Type
Doctoral Psychology Degree Type	Text	Provide the specific type of your doctoral psychology degree. Fill only if 'Psychologist, Clinical' is checked. Depends on: Psychologist, Clinical
Drug Enforcement Agency (DEA) Registration Information
Active DEA Registration	Checkbox	Check this box if you have an active Drug Enforcement Agency (DEA) registration. Fill only if 'Practitioner Specific Information' is 'Yes'.
Not Applicable	Checkbox	Check this box if Drug Enforcement Agency (DEA) registration information is not applicable to you. Fill only if 'Practitioner Specific Information' is 'Yes'.
DEA Registration Number	Text	Enter the Drug Enforcement Agency (DEA) registration number. Fill only if 'Active DEA Registration' is 'Yes'. Depends on: Active DEA Registration
DEA Registration Effective Date	Date	Provide the effective date of the Drug Enforcement Agency (DEA) registration. Fill only if 'Active DEA Registration' is 'Yes'. Depends on: Active DEA Registration
DEA Registration State Where Issued	Text	Enter the state where the Drug Enforcement Agency (DEA) registration was issued. Fill only if 'Active DEA Registration' is 'Yes'. Depends on: Active DEA Registration
Effective Date of Termination
Effective Date of Termination	Date	Provide the effective date when the Medicare enrollment was terminated. Fill only if '7. Voluntarily Terminating Medicare Enrollment' is 'Yes'. Depends on: 7. Voluntarily Terminating Medicare Enrollment
Eighth Initial Reporting Location
CITY/TOWN_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Electronic Records Storage Site
Site where electronic records are stored	Text	Depends on: 2. Electronic Storage. Do you store your patient medical records electronically? Yes
Electronic Storage Confirmation
No	CheckBox
2. Electronic Storage. Do you store your patient medical records electronically? Yes	CheckBox
Eleventh Initial Reporting Location
Eleventh Initial Reporting Location City/Town	Text	Enter the city or town for the eleventh initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Eleventh Initial Reporting Location County	Text	Enter the county for the eleventh initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Eleventh Initial Reporting Location State/Territory	Text	Enter the state or territory for the eleventh initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Eleventh Initial Reporting Location ZIP Code	Text	Enter the ZIP code for the eleventh initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Employee Relationship with Practitioner
1. What is the above individual’s relationship with the practitioner in section 2A? Contracted Managing Employee	CheckBox
W-2 Managing Employee	CheckBox
Exclusive Use of Private Office Space Status
Question 4: Exclusive Use No	Checkbox	Check this box if your private office space is not used exclusively for your private practice. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
Question 4: Exclusive Use Yes	Checkbox	Check this box if your private office space is used exclusively for your private practice. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
External Patient Services Status
2 No	Checkbox	Check this box if your private practice does not render services to patients from outside the institution or facility where your office is located. Fill only if 'Yes' is 'Yes'. Depends on: Yes
2 Yes	Checkbox	Check this box if your private practice renders services to patients from outside the institution or facility where your office is located. Fill only if 'Yes' is 'Yes'. Depends on: Yes
External PT/OT Services Status
5 No	Checkbox	Check this box if you do not provide Physical Therapy or Occupational Therapy services outside of your office and/or patients' homes. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
5 Yes	Checkbox	Check this box if you provide Physical Therapy or Occupational Therapy services outside of your office and/or patients' homes. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
Fifth Initial Reporting Location
CITY/TOWN_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Financial and Payment Documentation
Completed Form CMS-588	Checkbox	Check this box if you are submitting a completed Form CMS-588, Electronic Funds Transfer Authorization Agreement, along with a voided check or bank letter, unless you are currently receiving electronic payments and not changing banking information, or reassigning all payments to another entity. Fill only if 'If you DO have a private practice and ONLY render services in your own private practice' is 'Yes'. Depends on: DO have private practice, ONLY render services in own practice
If Medicare payments due to you are being sent to a bank (or similar financial institution) where you have a lending relationship (that is, any type of loan), you must provide a statement in writing from the bank (which must be in the loan agreement) that the bank has agreed to waive its right of offset for Medicare receivables	CheckBox
First Deletion Location
First Deletion City/Town	Text	Enter the city or town for the first location where services are no longer provided. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
First Deletion County	Text	Enter the county for the first location where services are no longer provided. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
First Deletion State/Territory	Text	Enter the state or territory for the first location where services are no longer provided. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
First Deletion Zip Code	Text	Enter the ZIP code for the first location where services are no longer provided. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
First Final Adverse Legal Action
First Final Adverse Legal Action	Text	Enter the details of the first final adverse legal action. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
First Final Adverse Legal Action Date	Date	Provide the date when the first final adverse legal action occurred. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
First Final Adverse Legal Action Taken By	Text	Enter the federal or state agency, court, or administrative body that imposed the first final adverse legal action. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
First Final Adverse Legal Action	Text	Enter the details of the first final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
First Final Adverse Legal Action Date	Date	Enter the date when the first final adverse legal action occurred. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
First Final Adverse Legal Action Taken By	Text	Enter the federal or state agency, court, or administrative body that imposed the first final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
If yes, report each final adverse legal action, when it occurred, and the federal or state agency or the court/administrative body that imposed the action. FINAL ADVERSE LEGAL ACTION_Row_1	Text	Depends on: Yes, continue below
DATE_Row_1	Text	Depends on: Yes, continue below
ACTION TAKEN BY_Row_1	Text	Depends on: Yes, continue below
First Initial Reporting Location
If services are only provided in selected cities/towns or counties, provide the locations below. Only list ZIP codes if you are not servicing the entire city/town or county. CITY/TOWN_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Fourth Deletion Location
Fourth Deletion City/Town	Text	Enter the city or town of the fourth location to be deleted from service. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Fourth Deletion County	Text	Enter the county of the fourth location to be deleted from service. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Fourth Deletion State/Territory	Text	Enter the state or territory of the fourth location to be deleted from service. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Fourth Deletion ZIP Code	Text	Enter the ZIP code of the fourth location to be deleted from service. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Fourth Initial Reporting Location
CITY/TOWN_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
General
Pracitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)	Signature
Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)	Signature
Home PT/OT Services Status
Home PT/OT Services Status: No	Checkbox	Check this box if you do not ONLY render Physical Therapy (PT) or Occupational Therapy (OT) services in the patients' homes. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
J. Physical/occupational therapist Information. Physical Therapists/Occupational Therapists in Private Practice (P.T./O.T.). 1. Do you ONLY render P.T./O.T. services in the patients’ homes? Yes	CheckBox
Hospital or Facility Name and Address
F. RESIDENT INFORMATION. 1. Provide the name and address of the hospital/facility where you are a resident. Name of Hospital Facility	Text
Street Address	Text
City/Town	Text
State	Text
State	Text
Independent Responsibility for Services
Independent Responsibility for Services - No	Checkbox	Check this box if you do not render services of your own responsibility free from the administrative control of an employer such as a physician, institution, or agency. Fill only if 'Psychologist Billing Independently' is checked. Depends on: Psychologist Billing Independently
Independent Responsibility for Services - Yes	Checkbox	Check this box if you render services of your own responsibility free from the administrative control of an employer such as a physician, institution, or agency. Fill only if 'Psychologist Billing Independently' is checked. Depends on: Psychologist Billing Independently
Individual Practitioner Action Details
Action Effective Date	Date	Enter the effective date for the individual practitioner's action. Fill only if 'Terminate', 'Add', 'Change' is selected, any. Depends on: Change, Add, Terminate
Terminate	Checkbox	Check this box if the reassignment of benefits for the individual practitioner is being terminated. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Add	Checkbox	Check this box if a new reassignment of benefits for the individual practitioner is being added. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Change	Checkbox	Check this box if there is a change in the reassignment of benefits information for the individual practitioner. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Individual Practitioner Identification Numbers
Social Security Number	CheckBox
Individual Practitioner SSN	Text	Enter the Social Security Number (SSN) of the individual practitioner, if applicable. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Employer Identitifcation Number (E.I.N.)	CheckBox
Individual Practitioner EIN	Text	Enter the Employer Identification Number (EIN) of the individual practitioner, if applicable. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Individual Practitioner Medicare ID Number (PTAN)	Text	Enter the Medicare Identification Number (PTAN) for the individual practitioner, if one has been issued; otherwise, write 'pending' if the initial enrollment application is being submitted concurrently. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Individual Practitioner NPI	Text	Enter the National Provider Identifier (NPI) for the individual practitioner. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Individual Practitioner Name
First Name	Text	Enter the individual practitioner's first name. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Middle Initial	Text	Enter the individual practitioner's middle initial. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Last Name	Text	Enter the individual practitioner's last name. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Suffix or Title	Text	Enter any suffix, such as Jr. or Sr., or professional titles like M.D., if applicable, for the individual practitioner. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Information Change Details
Information Change Effective Date	Date	Enter the effective date of the information change. Fill only if 'Section Not Applicable', 'Add', 'Remove', 'Change' is 'No' and any of checkboxes 17, 15, 16 is selected. Depends on: Section Not Applicable, Change, Add, Remove
Add	Checkbox	Check this box if you are adding new billing agency/agent information. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Remove	Checkbox	Check this box if you are removing billing agency/agent information. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Change	Checkbox	Check this box if you are changing information about your current billing agency/agent. Fill only if 'Section Not Applicable' is 'No'. Depends on: Section Not Applicable
Initial Reporting Entire State
specify the State	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state	CheckBox
IRS Business Registration Documentation
IRS TIN & Legal Business Name Confirmation	Checkbox	Check this box if you are providing written confirmation from the IRS confirming your Tax Identification Number and Legal Business Name, as required for certain entity types or sole proprietors using an EIN. Fill only if 'If you are a sole proprietor and want Medicare payments to be paid under your EIN, please check this box and fill in the EIN information below' is 'Yes'. Depends on: Medicare payments under EIN
IRS LLC Disregarded Entity Confirmation	Checkbox	Check this box if you are providing written confirmation from the IRS that your Limited Liability Company (LLC) is automatically classified as a Disregarded Entity. Fill only if 'Disregarded Entity' is 'Yes'. Depends on: Disregarded Entity
IRS Non-Profit Determination Letter	Checkbox	Check this box if you are providing a copy of your IRS Determination Letter confirming your non-profit status. Fill only if 'Non-Profit' is 'Yes'. Depends on: Non-Profit
Managing Employee Contact Information
Telephone Number	Text
Fax Number (if applicable)	Text
E-mail Address (if applicable)	Text
Managing Employee Declaration
I am the managing employee	Checkbox	Check this box if you are the managing employee described in this section, and you will then skip to section 8. Fill only if 'Reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Managing Employee Identification Numbers
Medicare Identification Number (if issued)	Text
N P I (if issued)	Text
Managing Employee Name
First Name	Text
Middle Initial	Text
Last Name	Text
Jr., Sr., M.D., etc	Text
Managing Employee Personal Information
Social Security Number	Text
Date of Birth. 2 digit month, 2 digit day, 4 digit year	Text
Managing Employee Update Information
Effective Date	Date	Provide the date when the change, addition, or removal of the managing employee becomes effective. Fill only if 'Add', 'Remove', 'A. MANAGING EMPLOYEE IDENTIFYING INFORMATION. If you are changing information about your current managing employee or adding or removing a managing employee, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change' is checked, any. Depends on: A. MANAGING EMPLOYEE IDENTIFYING INFORMATION. If you are changing information about your current managing employee or adding or removing a managing employee, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add, Remove
Add	CheckBox
Remove	CheckBox
A. MANAGING EMPLOYEE IDENTIFYING INFORMATION. If you are changing information about your current managing employee or adding or removing a managing employee, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change	CheckBox
Medical Record Address Option
E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section	CheckBox
Medical Record Contact Information
Telephone Number (if applicable)	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
Fax Number (if applicable)	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
E-mail Address (if applicable)	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
Medical Record Correspondence Address
Attention optional	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
Medical Record Correspondence Address Line 1 (P.O. Box or Street Name and Number	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
Medical Record Correspondence Address Line 2 (Suite, Room, Apt. #, etc	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
City/Town	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
State	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
5 digit Zip code +4 digits	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
Medical Record Correspondence Address Change
Change	CheckBox	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section
Effective date. 2 digit month, 2 digit day, 4 digit year	Text	Depends on: E. MEDICAL RECORD CORRESPONDENCE ADDRESS. Check here if your Medical Record Correspondence Address should be mailed to your Correspondence Address in section 2D above and skip this section, Change
Medicare Participation Agreement
Completed Form CMS-460	Checkbox	Check this box if you have completed and are submitting Form CMS-460 for initial enrollment or reactivation, indicating your intention to be a Participating Practitioner in Medicare. Fill only if 'You are a new enrollee in Medicare' is 'Yes'. Depends on: 1. New Enrollee in Medicare
Ninth Initial Reporting Location
Ninth Initial Reporting City/Town	Text	Enter the city or town for the ninth initial reporting location where healthcare services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Ninth Initial Reporting County	Text	Enter the county for the ninth initial reporting location where healthcare services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Ninth Initial Reporting State/Territory	Text	Enter the state or territory for the ninth initial reporting location where healthcare services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Ninth Initial Reporting ZIP Code	Text	Enter the ZIP code for the ninth initial reporting location where healthcare services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Non-Physician Specialty Type
Anesthesiology Assistant	Checkbox	Check this box if your non-physician specialty type is Anesthesiology Assistant.
Certified Nurse Midwife (CNM)	Checkbox	Check this box if your non-physician specialty type is Certified Nurse Midwife (CNM).
Certified Registered Nurse Anesthetist (CRNA)	Checkbox	Check this box if your non-physician specialty type is Certified Registered Nurse Anesthetist (CRNA).
Clinical Nurse Specialist (CNS)	Checkbox	Check this box if your non-physician specialty type is Clinical Nurse Specialist (CNS).
Clinical Social Worker	Checkbox	Check this box if your non-physician specialty type is Clinical Social Worker.
Mass Immunization Roster Biller	Checkbox	Check this box if your non-physician specialty type is Mass Immunization Roster Biller.
Nurse Practitioner	Checkbox	Check this box if your non-physician specialty type is Nurse Practitioner.
Occupational Therapist in Private Practice	Checkbox	Check this box if your non-physician specialty type is Occupational Therapist in Private Practice.
Physical Therapist in Private Practice	Checkbox	Check this box if your non-physician specialty type is Physical Therapist in Private Practice.
Physician Assistant	Checkbox	Check this box if your non-physician specialty type is Physician Assistant.
Psychologist, Clinical	Checkbox	Check this box if your non-physician specialty type is Psychologist, Clinical.
Psychologist Billing Independently	Checkbox	Check this box if your non-physician specialty type is Psychologist Billing Independently.
Qualified Audiologist	Checkbox	Check this box if your non-physician specialty type is Qualified Audiologist.
Qualified Speech Language Pathologist	Checkbox	Check this box if your non-physician specialty type is Qualified Speech Language Pathologist.
Registered Dietitian or Nutrition Professional	Checkbox	Check this box if your non-physician specialty type is Registered Dietitian or Nutrition Professional.
Undefined Non-Physician Practitioner Specialty	Checkbox	Check this box if your non-physician specialty type is an Undefined Non-Physician Practitioner Specialty.
Undefined Non-Physician Practitioner Specialty	Text	Enter the specific type of undefined non-physician practitioner specialty. Fill only if 'Undefined Non-Physician Practitioner Specialty' is checked. Depends on: Undefined Non-Physician Practitioner Specialty
Office Confinement Status
1. Office Confined - No	Checkbox	Check this box if your private practice office is not confined to a separately identified part of the institution/facility, or if it can be construed as extending throughout the entire facility. Fill only if 'Yes' is 'Yes'. Depends on: Yes
1. Office Confined - Yes	Checkbox	Check this box if your private practice office is confined to a separately identified part of the institution/facility and is used solely as your office, not extending throughout the entire facility. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Organization/Group Action Details
2. Organization/Group Effective Date	Date	Provide the effective date for the organization or group action. Fill only if 'Organization/Group Terminate Action', 'Organization/Group Add Action', 'Organization/Group Change Action' is selected, any. Depends on: Organization/Group Change Action, Organization/Group Add Action, Organization/Group Terminate Action
Organization/Group Terminate Action	Checkbox	Check this box if the organization/group is terminating a currently established reassignment of Medicare benefits. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Organization/Group Add Action	Checkbox	Check this box if the organization/group is accepting a new reassignment of Medicare benefits from an individual practitioner. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Organization/Group Change Action	Checkbox	Check this box if you are making a change in the reassignment of Medicare benefit information for the organization/group. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Organization/Group Identification Numbers
Organization/Group Tax Identification Number (TIN)	Text	Enter the Tax Identification Number (TIN) for the organization or group. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Organization/Group Medicare Identification Number (PTAN)	Text	Enter the Medicare Identification Number (PTAN) for the organization or group, if issued. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Organization/Group National Provider Identifier (NPI)	Text	Enter the National Provider Identifier (NPI) for the organization or group. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Organization/Group Legal Business Name
Organization/Group Legal Business Name	Text	Enter the legal business name of the organization or group as reported to the Internal Revenue Service. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'Yes'. Depends on: Do NOT have private practice, reassign ALL benefits
Other Name
Other Name, First Name	Text	Enter the first name for the other name being provided. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Other Name, Middle Initial	Text	Enter the middle initial for the other name being provided. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Other Name, Last Name	Text	Enter the last name for the other name being provided. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Other Name, Suffix	Text	Enter any suffix or title, such as Jr., Sr., or M.D., for the other name being provided. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
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Assign Section 2A Individual as Contact Person	Checkbox	Check this box to designate the individual listed in section 2A of this application as the contact person.
Effective Date	Date	Enter the effective date.
First Name	Text	Enter the first name of the contact person.
Middle Initial	Text	Enter the middle initial of the contact person.
Last Name	Text	Enter the last name of the contact person.
Suffix	Text	Enter any applicable suffix such as Jr., Sr., MD, etc.
Address Line 1	Text	Enter the street name and number for contact person's address.
Address Line 2	Text	Enter the suite, room, or apartment number for contact person's address.
City/Town	Text	Enter the city or town of the contact person's address.
State	Text	Enter the state of the contact person's address.
ZIP Code + 4	Text	Enter the ZIP Code and the optional four-digit extension.
Telephone Number	Text	Enter the contact person's telephone number.
Fax Number	Text	Enter the contact person's fax number, if applicable.
Email Address	Text	Enter the contact person's email address, if applicable.
Relationship or Affiliation	Text	Enter the relationship or affiliation of the contact person to the individual or organization/group.
Add Contact Person	Checkbox	Check this box to add a new contact person.
Remove Contact Person	Checkbox	Check this box to remove the current contact person.
Change Contact Person	Checkbox	Check this box to indicate that there is a change to the contact person's details.
Paper Storage Confirmation
No	CheckBox
1. Paper Storage. Do you store your patient medical records in a physical location? Yes	CheckBox
Paper Storage Facility Address
Paper Storage Facility Name	Text	Enter the name of the paper storage facility. Fill only if '1. Paper Storage. Do you store your patient medical records in a physical location? Yes' is 'Yes'. Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
Paper Storage Address Line 1	Text	Enter the street name and number for the paper storage facility address. Fill only if '1. Paper Storage. Do you store your patient medical records in a physical location? Yes' is 'Yes'. Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
Paper Storage Address Line 2	Text	Enter the suite, room, or apartment number, or any additional address details for the paper storage facility. Fill only if '1. Paper Storage. Do you store your patient medical records in a physical location? Yes' is 'Yes'. Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
Paper Storage City/Town	Text	Enter the city or town for the paper storage facility address. Fill only if '1. Paper Storage. Do you store your patient medical records in a physical location? Yes' is 'Yes'. Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
Paper Storage State	Text	Enter the state for the paper storage facility address. Fill only if '1. Paper Storage. Do you store your patient medical records in a physical location? Yes' is 'Yes'. Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
Paper Storage ZIP Code + 4	Text	Enter the ZIP code including the +4 extension for the paper storage facility address. Fill only if '1. Paper Storage. Do you store your patient medical records in a physical location? Yes' is 'Yes'. Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
Patient Treatment Status
Treat Own Patients - No	Checkbox	Check this box if you do not treat your own patients. Fill only if 'Psychologist Billing Independently' is checked. Depends on: Psychologist Billing Independently
Treat Own Patients - Yes	Checkbox	Check this box if you treat your own patients. Fill only if 'Psychologist Billing Independently' is checked. Depends on: Psychologist Billing Independently
Payment Arrangement
Medicare payments under SSN	Checkbox	Check this box if you want your Medicare payments to be paid under your Social Security Number. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Medicare payments under EIN	Checkbox	Check this box if you are a sole proprietor and want your Medicare payments to be paid under your Employer Identification Number. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Payment Arrangement EIN	Text	Provide the Employer Identification Number (EIN) for this payment arrangement. Fill only if 'Medicare payments under EIN' is 'Yes'. Depends on: Medicare payments under EIN
Physician Specialty Selection
G. Physician Specialty. Designate your primary specialty and all secondary specialty(s) below using: P=Primary S=Secondary. Addiction Medicine	Text	Max length: 1 characters
Adult Congenital Heart Disease	Text	Max length: 1 characters
Advanced Heart Failure and Transplant Cardiology	Text	Max length: 1 characters
Allergy/Immunology	Text	Max length: 1 characters
Anesthesiology	Text	Max length: 1 characters
Cardiac Electrophysiology	Text	Max length: 1 characters
Cardiac Surgery	Text	Max length: 1 characters
Cardiovascular Disease (Cardiology)	Text	Max length: 1 characters
Chiropractic	Text	Max length: 1 characters
Colorectal Surgery (Proctology)	Text	Max length: 1 characters
Critical Care Intensivists	Text	Max length: 1 characters
Dentist	Text	Max length: 1 characters
Dermatology	Text	Max length: 1 characters
Diagnostic Radiology	Text	Max length: 1 characters
Emergency Medicine	Text	Max length: 1 characters
Endocrinology	Text	Max length: 1 characters
Family Medicine	Text	Max length: 1 characters
Gastroenterology	Text	Max length: 1 characters
General Practice	Text	Max length: 1 characters
General Surgery	Text	Max length: 1 characters
Geriatric Medicine	Text	Max length: 1 characters
Geriatric Psychiatry	Text	Max length: 1 characters
Gynecological Oncology	Text	Max length: 1 characters
Hand Surgery	Text	Max length: 1 characters
Hematology	Text	Max length: 1 characters
Hematology/Oncology	Text	Max length: 1 characters
Hematopoietic Cell Transplantation and Cellular Therapy	Text	Max length: 1 characters
Hospice/Palliative Care	Text	Max length: 1 characters
Hospitalist	Text	Max length: 1 characters
Infectious Disease	Text	Max length: 1 characters
Internal Medicine	Text	Max length: 1 characters
Interventional Cardiology	Text	Max length: 1 characters
Interventional Pain Management	Text	Max length: 1 characters
Interventional Radiology	Text	Max length: 1 characters
Maxillofacial Surgery	Text	Max length: 1 characters
Medical Genetics and Genomics	Text	Max length: 1 characters
Medical Oncology	Text	Max length: 1 characters
Medical Toxicology	Text	Max length: 1 characters
Micrographic Dermatologic Surgery	Text	Max length: 1 characters
Nephrology	Text	Max length: 1 characters
Neurology	Text	Max length: 1 characters
Neuropsychiatry	Text	Max length: 1 characters
Neurosurgery	Text	Max length: 1 characters
Nuclear Medicine	Text	Max length: 1 characters
Obstetrics/Gynecology	Text	Max length: 1 characters
Ophthalmology	Text	Max length: 1 characters
Optometry	Text	Max length: 1 characters
Oral Surgery	Text	Max length: 1 characters
Orthopedic Surgery	Text	Max length: 1 characters
Osteopathic Manipulative Medicine	Text	Max length: 1 characters
Otolaryngology	Text	Max length: 1 characters
Pain Management	Text	Max length: 1 characters
Pathology	Text	Max length: 1 characters
Pediatric Medicine	Text	Max length: 1 characters
Peripheral Vascular Disease	Text	Max length: 1 characters
Physical Medicine and Rehabilitation	Text	Max length: 1 characters
Plastic and Reconstructive Surgery	Text	Max length: 1 characters
Podiatry	Text	Max length: 1 characters
Preventive Medicine	Text	Max length: 1 characters
Psychiatry	Text	Max length: 1 characters
Pulmonary Disease	Text	Max length: 1 characters
Radiation Oncology	Text	Max length: 1 characters
Rheumatology	Text	Max length: 1 characters
Sleep Medicine	Text	Max length: 1 characters
Sports Medicine	Text	Max length: 1 characters
Surgical Oncology	Text	Max length: 1 characters
Thoracic Surgery	Text	Max length: 1 characters
Undersea and Hyperbaric Medicine	Text	Max length: 1 characters
Urology	Text	Max length: 1 characters
Vascular Surgery	Text	Max length: 1 characters
Undefined Physician Specialty	Text	Max length: 1 characters
Undefined Physician Specialty, Specify	Text	Depends on: Undefined Physician Specialty
Practice Location Action
Practice Location Action Effective Date	Date	Enter the effective date for the practice location action. Fill only if 'Add Practice Location', 'Change Practice Location', 'Remove Practice Location' is 'Yes' for any. Depends on: Add Practice Location, Change Practice Location, Remove Practice Location
Add Practice Location	Checkbox	Check this box if you are adding a new practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Change Practice Location	Checkbox	Check this box if you are changing information about a currently reported practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Remove Practice Location	Checkbox	Check this box if you are removing a practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Practice Location Information
Practice Location Name	Text	Enter the legal or "Doing Business As" name of the practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Practice Location Street Address Line 1	Text	Enter the first line of the street address for the practice location, excluding P.O. Box numbers. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Practice Location Street Address Line 2	Text	Enter the second line of the street address, including suite, room, or apartment numbers if applicable. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
City/Town	Text	Enter the city or town of the practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
State	Text	Enter the two-letter abbreviation for the state of the practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
ZIP Code + 4	Text	Enter the five-digit ZIP code for the practice location, optionally followed by the four-digit extension. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Telephone Number	Text	Enter the primary telephone number for the practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Fax Number	Text	Enter the fax number for the practice location, if applicable. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
E-mail Address	Text	Enter the e-mail address for the practice location, if applicable. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Medicare Identification Number (PTAN)	Text	Enter the Medicare Identification Number (PTAN) for this practice location, if one has been issued. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
First Medicare Patient Date	Date	Enter the date you saw or expect to see your first Medicare patient at this practice location. Fill only if 'Do not have a private practice and reassign all benefits' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Practice Location Storage Confirmation
Records stored at practice location	Checkbox	Check this box if all Medicare beneficiary medical records are stored at the practice location reported in section 4B. Fill only if 'If you DO have a private practice and ONLY render services in your own private practice' is 'Yes'. Depends on: DO have private practice, ONLY render services in own practice
Practitioner Name
Practitioner First Name	Text	Provide the first name of the practitioner.
Practitioner Middle Initial	Text	Provide the middle initial of the practitioner.
Practitioner Last Name	Text	Provide the last name of the practitioner.
Practitioner Suffix/Title	Text	Provide any applicable suffix or professional title for the practitioner, such as Jr., Sr., M.D., etc.
Primary Practice Location
No	Checkbox	Check this box if this is not your primary practice location. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Yes	Checkbox	Check this box if this is your primary practice location. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Effective date. 2 digit month, 2 digit day, 4 digit year	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Practice Location Name (“Doing Business As” Name	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Practice Location Street Address Line 2 (Suite, Room, Apt. #, etc	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
City/Town	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
State	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
ZIP Code + 4	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Medicare Identification Number for this location – P.T.A.N. (if issued)	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
National Provider Identifier (N.P.I.)	Text	Depends on: Remove, a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Remove	CheckBox
a. Primary Practice Location. If you are changing information about a currently reported primary practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change	CheckBox
Add	CheckBox
Private Office Space Maintenance Status
Private Office Space Maintained - No	Checkbox	Check this box if you do not maintain private office space. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
Private Office Space Maintained - Yes	Checkbox	Check this box if you maintain private office space. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
Private Office Space Ownership Status
Own, Lease, or Rent Private Office Space - No	Checkbox	Check this box if you do not own, lease, or rent your private office space. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
Own, Lease, or Rent Private Office Space - Yes	Checkbox	Check this box if you own, lease, or rent your private office space. Fill only if 'Physical Therapist in Private Practice' is 'Yes'. Depends on: Physical Therapist in Private Practice
Private Practice Location Status
No	Checkbox	Check this box if your private practice is not located in an institution or other facility. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Yes	Checkbox	Check this box if your private practice is located in an institution or other facility. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Private Practice Location Type
Ambulatory Surgical Center	Checkbox	Check this box if your private practice location is an Ambulatory Surgical Center. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Business Office for Administrative/Telehealth Use Only	Checkbox	Check this box if your private practice location is a Business Office used solely for administrative or telehealth purposes. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Home Office for Administrative/Telehealth Use Only	Checkbox	Check this box if your private practice location is a Home Office used solely for administrative or telehealth purposes. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Hospital/Hospital Department	Checkbox	Check this box if your private practice location is a Hospital or a Hospital Department. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Indian Health Services (IHS) or Tribal Facility	Checkbox	Check this box if your private practice location is an Indian Health Services (IHS) facility or a Tribal Facility. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Private Office Setting	Checkbox	Check this box if your private practice location is a Private Office Setting. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Retirement or Assisted Living Community	Checkbox	Check this box if your private practice location is a Retirement or Assisted Living Community. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Skilled Nursing Facility or Other Nursing Facility	Checkbox	Check this box if your private practice location is a Skilled Nursing Facility or any other type of Nursing Facility. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Other Health Care Facility	Checkbox	Check this box if your private practice location is an 'Other Health Care Facility' not listed in the options above. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Other Health Care Facility Specify	Text	Specify the type of other healthcare facility for your private practice location. Fill only if 'Other Health Care Facility' is 'Yes'. Depends on: Other Health Care Facility
Professional Certification and Education Documentation
Current copy of certification and proof of educational requirements	Checkbox	Check this box if you are submitting a current copy of certification and proof of educational requirements for eligible professionals or other non-physician specialty types who provide acupuncture services. Fill only if 'Does the physician assistant, nurse practitioner, or clinical nurse specialist identified in section 2A provide acupuncture services' is 'Yes'. Depends on: Acupuncture Services Status: Yes
Professional School Information
Medical or other Professional School (Training Institution, if non-MD)	Text
Year of Graduation. 4 digit year	Text
Provider Identification Numbers
Medicare Identification Number (PTAN)	Text	Please enter the Medicare Identification Number (PTAN) if one has been issued. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
National Provider Identifier (NPI)	Text	Please enter the National Provider Identifier (NPI) for the individual. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Provider Name
Provider First Name	Text	Enter the provider's first name. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Provider Middle Initial	Text	Enter the provider's middle initial. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Provider Last Name	Text	Enter the provider's last name. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Provider Suffix/Title	Text	Enter any suffix or title for the provider, such as Jr., Sr., or M.D. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Reason for Submitting This Application
1. New Enrollee in Medicare	Checkbox	Check this box if you are a new enrollee in Medicare.
2. Enroll as Individual Practitioner	Checkbox	Check this box if you are currently enrolled in Medicare to order and certify and wish to enroll as an Individual Practitioner.
3. Enroll with another MAC	Checkbox	Check this box if you are enrolling with a different Medicare Administrative Contractor (MAC).
4. Revalidating Medicare Enrollment	Checkbox	Check this box if you are revalidating your existing Medicare enrollment.
5. Reactivating Medicare Enrollment	Checkbox	Check this box if you are reactivating your Medicare enrollment.
6. Reporting Enrollment Change	Checkbox	Check this box if you are reporting a change to your Medicare enrollment information, including establishing or terminating a reassignment.
7. Voluntarily Terminating Medicare Enrollment	Checkbox	Check this box if you are voluntarily terminating your Medicare enrollment.
Remittance Notice/Special Payments Mailing Options
Mail to Practice Location Address	Checkbox	Check this box if your Remittance Notice/Special Payments should be mailed to your Practice Location Address in section 4B, and skip this section. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual, check this box and only complete section 4F.' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Mail to Correspondence Address	Checkbox	Check this box if your Remittance Notice/Special Payments should be mailed to your Correspondence Address in section 2D, and skip this section. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual, check this box and only complete section 4F.' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Render Services at Other Locations Question
Render Services at Other Locations - Yes	Checkbox	Check this box if you render services at other facilities or practice locations. Fill only if 'Are the services that you render at the hospital/facility shown in section 2F1 part of your requirements for graduation from a formal residency or program?' is 'Yes'. Depends on: Residency Program Requirement: Yes
Render Services at Other Locations - No	Checkbox	Check this box if you do not render services at other facilities or practice locations. Fill only if 'Are the services that you render at the hospital/facility shown in section 2F1 part of your requirements for graduation from a formal residency or program?' is 'Yes'. Depends on: Residency Program Requirement: Yes
Residency Program Details
Residency Program Completion Date	Date	Enter the date when the residency program was completed. Fill only if 'Residency Program Requirement: Yes' is 'Yes'. Depends on: Residency Program Requirement: Yes
Residency Program Requirement: No	Checkbox	Check this box if the services you render at the hospital/facility are not part of your requirements for graduation from a formal residency or program. Fill only if 'Practitioner Specific Information' is 'Yes'.
Residency Program Requirement: Yes	Checkbox	Check this box if the services you render at the hospital/facility are part of your requirements for graduation from a formal residency or program. Fill only if 'Practitioner Specific Information' is 'Yes'.
Residency Program Requirements Question
Residency Program Requirements Yes	Checkbox	Check this box if the services you render in the reported practice locations are part of your requirements for graduation from a residency program. Fill only if 'Are the services that you render at the hospital/facility shown in section 2F1 part of your requirements for graduation from a formal residency or program?' is 'Yes'. Depends on: Residency Program Requirement: Yes
Residency Program Requirements No	Checkbox	Check this box if the services you render in the reported practice locations are not part of your requirements for graduation from a residency program. Fill only if 'Are the services that you render at the hospital/facility shown in section 2F1 part of your requirements for graduation from a formal residency or program?' is 'Yes'. Depends on: Residency Program Requirement: Yes
Second Deletion Location
Second Deletion City/Town	Text	Enter the city or town of the second location to be deleted. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Second Deletion County	Text	Enter the county of the second location to be deleted. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Second Deletion State/Territory	Text	Enter the state or territory of the second location to be deleted. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Second Deletion Zip Code	Text	Enter the ZIP code of the second location to be deleted. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Second Final Adverse Legal Action
Second Final Adverse Legal Action Details	Text	Enter the details of the second final adverse legal action. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Second Final Adverse Legal Action Date	Date	Enter the date when the second final adverse legal action occurred. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Second Final Adverse Legal Action Imposing Agency	Text	Enter the federal or state agency, court, or administrative body that imposed the second final adverse legal action. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Second Final Adverse Legal Action	Text	Provide the details of the second final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Second Final Adverse Legal Action Date	Date	Enter the date when the second final adverse legal action occurred. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Second Final Adverse Legal Action Taken By	Text	Enter the federal or state agency, court, or administrative body that imposed the second final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
FINAL ADVERSE LEGAL ACTION_Row_2	Text	Depends on: Yes, continue below
DATE_Row_2	Text	Depends on: Yes, continue below
ACTION TAKEN BY_Row_2	Text	Depends on: Yes, continue below
Second Initial Reporting Location
CITY/TOWN_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Secondary Practice Location
Effective date. 2 digit month, 2 digit day, 4 digit year	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Practice Location Name (“Doing Business As” Name)	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Practice Location Street Address Line 2 (Suite, Room, Apt. #, etc.)	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
City/Town	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
State	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
ZIP Code + 4	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Medicare Identification Number for this location – P.T.A.N. (if issued)	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
National Provider Identifier (N.P.I.)	Text	Depends on: Remove, b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Add
Remove	CheckBox
b. Secondary Practice Location. If you are changing information about a currently reported additional practice location or adding or removing an additional practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change	CheckBox
Add	CheckBox
SECTION 4: BUSINESS INFORMATION
Do NOT have private practice, reassign ALL benefits	Checkbox	Check this box if you do not have a private practice but reassign all of your benefits to an organization or individual. Fill only if 'Do you also render services at other facilities or practice locations?' is 'Yes'. Depends on: Render Services at Other Locations - Yes
DO have private practice, reassign ANY benefits	Checkbox	Check this box if you have a private practice and reassign any of your benefits to an organization or individual. Fill only if 'Do you also render services at other facilities or practice locations?' is 'Yes'. Depends on: Render Services at Other Locations - Yes
DO have private practice, ONLY render services in own practice	Checkbox	Check this box if you have a private practice and only render services in your own private practice. Fill only if 'Do you also render services at other facilities or practice locations?' is 'Yes'. Depends on: Render Services at Other Locations - Yes
Section Applicability
Section Not Applicable	Checkbox	Check this box if the Section 8: Billing Agency/Agent Information does not apply to you, and you should skip to section 12. Fill only if 'If you do NOT have a private practice but you reassign ALL of your benefits to an organization/group or individual' is 'No'. Depends on: Do NOT have private practice, reassign ALL benefits
Seventh Initial Reporting Location
CITY/TOWN_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Sixth Initial Reporting Location
CITY/TOWN_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Skilled Nursing Facility Information
Skilled Nursing Facility Name	Text	Enter the full name of the skilled nursing facility. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
Skilled Nursing Facility Address Line 1	Text	Provide the primary street address for the skilled nursing facility, including the street name and number. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
Skilled Nursing Facility Address Line 2	Text	Provide any additional address details for the skilled nursing facility, such as suite or room number. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
City/Town	Text	Enter the city or town where the skilled nursing facility is located. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
State	Text	Enter the state where the skilled nursing facility is located. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
ZIP Code	Text	Enter the ZIP code for the skilled nursing facility, including the optional four-digit extension. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
SNF Tax Identification Number	Text	Enter the tax identification number for the skilled nursing facility. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
Telephone Number	Text	Enter the primary telephone number for the skilled nursing facility. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
Fax Number	Text	If applicable, enter the fax number for the skilled nursing facility. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
Email Address	Text	If applicable, enter the email address for the skilled nursing facility. Fill only if 'SNF Yes' is 'Yes'. Depends on: SNF Yes
SNF Employment Status
SNF No	Checkbox	Check this box if you are NOT an employee of a skilled nursing facility (SNF) or of another entity that has an agreement to provide nursing services to a SNF. Fill only if 'Clinical Nurse Specialist (CNS)' is 'Yes'. Depends on: Clinical Nurse Specialist (CNS)
SNF Yes	Checkbox	Check this box if you are an employee of a skilled nursing facility (SNF) or of another entity that has an agreement to provide nursing services to a SNF. Fill only if 'Clinical Nurse Specialist (CNS)' is 'Yes'. Depends on: Clinical Nurse Specialist (CNS)
Social Security Number and Date of Birth
Social Security Number	Text	Enter the Social Security Number (SSN). Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Date of Birth	Date	Enter the individual's date of birth. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Special Payments Mailing Address
Special Payments Address Line 1	Text	Enter the first line of the special payments mailing address, which may include a P.O. Box or street name and number. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No' for all dependency fields. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments Address Line 2	Text	Enter the second line of the special payments mailing address, such as a suite, room, or apartment number. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No' for all dependency fields. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments City/Town	Text	Enter the city or town for the special payments mailing address. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No' for all dependency fields. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments State	Text	Enter the state for the special payments mailing address. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No' for all dependency fields. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments ZIP Code + 4	Text	Enter the ZIP code, including the plus four extension, for the special payments mailing address. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No' for all dependency fields. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Storage Location Change
Effective Date	Date	Provide the effective date for adding or removing a storage location. Fill only if 'Remove', 'If you are adding or removing a storage location, check the applicable box below and furnish the effective date. Add' is checked, any. Depends on: Remove, If you are adding or removing a storage location, check the applicable box below and furnish the effective date. Add
Remove	CheckBox
If you are adding or removing a storage location, check the applicable box below and furnish the effective date. Add	CheckBox
Teaching Hospital Cost Coverage Question
If yes, has the teaching hospital/facility reported in section 2F1 above agreed to incur all or substantially all of the costs of your training in the non-hospital/facility location? Yes	CheckBox	Depends on: Residency Program Requirements Yes
No	CheckBox	Depends on: Residency Program Requirements Yes
Tenth Initial Reporting Location
Tenth Initial Reporting City/Town	Text	Enter the city or town for the tenth initial reporting location where health care services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Tenth Initial Reporting County	Text	Enter the county for the tenth initial reporting location where health care services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Tenth Initial Reporting State/Territory	Text	Enter the state or territory for the tenth initial reporting location where health care services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Tenth Initial Reporting Zip Code	Text	Enter the ZIP code for the tenth initial reporting location where health care services are rendered in patients' homes. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Third Deletion Location
Third Deletion City/Town	Text	Enter the city or town for the third deletion location. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Third Deletion County	Text	Enter the county for the third deletion location. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Third Deletion State/Territory	Text	Enter the state or territory for the third deletion location. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Third Deletion ZIP Code	Text	Enter the ZIP code for the third deletion location. Fill only if 'Deletion Entire State' is 'No'. Depends on: Deletion Entire State
Third Final Adverse Legal Action
Third Final Adverse Legal Action Details	Text	Provide a detailed report of the third final adverse legal action that occurred. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Third Action Date	Date	Enter the date on which the third final adverse legal action occurred. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Third Action Imposing Body	Text	Specify the federal or state agency, court, or administrative body that imposed the third final adverse legal action. Fill only if 'Adverse Legal Action History Confirmation Yes' is 'Yes'. Depends on: Adverse Legal Action History Confirmation Yes
Third Final Adverse Legal Action	Text	Enter the details of the third final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Third Final Adverse Legal Action Date	Date	Enter the date when the third final adverse legal action occurred. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Third Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or the court/administrative body that imposed the third final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Third Final Adverse Legal Action	Text	Enter a description of the third final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Third Final Adverse Legal Action Date	Date	Enter the date when the third final adverse legal action occurred. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Third Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or court/administrative body that imposed the third final adverse legal action. Fill only if 'Yes, continue below' is 'Yes'. Depends on: Yes, continue below
Third Initial Reporting Location
CITY/TOWN_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Initial Reporting Location
Twelfth Initial Reporting City/Town	Text	Enter the city or town for the twelfth initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Initial Reporting County	Text	Enter the county for the twelfth initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Initial Reporting State/Territory	Text	Enter the state or territory for the twelfth initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Initial Reporting ZIP Code	Text	Enter the ZIP code for the twelfth initial reporting location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Type of Other Name
Former or Maiden Name	Checkbox	Check this box if the 'Other Name' refers to a former or maiden name. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Professional Name	Checkbox	Check this box if the 'Other Name' refers to a professional name. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Other (Describe)	Checkbox	Check this box if the 'Other Name' is a type not listed, and provide a description in the space provided. Fill only if 'You are reporting a change to your Medicare enrollment information' is 'Yes'. Depends on: 6. Reporting Enrollment Change
Other Name Type Description	Text	Provide a description for the 'Other' type of name. Fill only if 'Other (Describe)' is 'Yes'. Depends on: Other (Describe)
What Information is Changing
B. WHAT INFORMATION IS CHANGING? Check all that apply and complete the required sections. Personal Identifying Information	CheckBox
Final adverse legal action	CheckBox
Medical Specialty Information	CheckBox
Supllier Specific Information	CheckBox
Physician Assistant Employment Arrangements	CheckBox
Private Practice Business Information	CheckBox
Managing Employee Information	CheckBox
Address Information	CheckBox
Billing Agency Information	CheckBox
Any other information not specified above	CheckBox

CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners Instructions