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.
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 |
