Form CMS-855O, Medicare Enrollment Application Completed Form Examples and Samples

Explore a detailed example of a completed CMS-855O Medicare Enrollment Application for individual physician enrollment. This example features Dr. Jane Smith, a neurologist, showcasing accurate entries, including UPIN, NPI, and practice details for Medicare enrollment.
Form CMS-855O, Medicare Enrollment Application has a complex Form Complexity Index of 63/100 — Instafill’s AI completes it in under a minute.
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Completed CMS-855O Form for individual physician enrollment

CMS-855O Example – Individual Physician Enrollment

How this form was filled:

Dr. Jane Smith, a practicing neurologist, seeks Medicare enrollment to order and refer items or services. Her details include a valid UPIN and NPI, with her practice location listed. The form is signed and dated accurately.

Information used to fill out the document:

  • Physician’s Name: Dr. Jane Smith
  • Specialty: Neurology
  • UPIN: S12345
  • NPI: 1234567890
  • Practice Location: 456 Health Blvd, Midtown, USA
  • Signature: Dr. Jane Smith
  • Date: 03/15/2025

What this filled form sample shows:

  • Accurate entry of physician’s personal and practice details
  • Inclusion of valid UPIN and NPI for identification
  • Correct signature and date format
  • Detailed practice location information for verification

Form specifications and details:

Use Case: Individual Physician Enrollment to order and refer under Medicare
Categories: CAR forms, CMS forms, EDI enrollment forms, enrollment application forms, enrollment forms, healthcare provider forms, medical enrollment forms, Medicare application forms, Medicare enrollment forms, Medicare forms, physician application forms, physician enrollment forms, physician forms, L.A. Care forms
Completed CMS-855O Form for individual physician enrollment