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, Medicare application forms, Medicare enrollment forms, Medicare forms, L.A. Care forms
Completed CMS-855O Form for individual physician enrollment