Form CMS-855O, Medicare Enrollment Application Instructions

Specify any other relevant information that does not fit into the predefined categories.

Provide a detailed description of any other relevant information that does not fit into the predefined categories.

Indicate if you have ever had a final adverse legal action imposed against you under any current or former name or business identity. Select 'YES' to continue providing details.

Indicate if you have never had a final adverse legal action imposed against you. Select 'NO' to skip to section 4.

Provide details of the final adverse legal action imposed against you.

Enter the date when the final adverse legal action was imposed.

Specify the entity or authority that took the final adverse legal action against you.

Provide details of another final adverse legal action imposed against you, if applicable.

Enter the date when the additional final adverse legal action was imposed.

Specify the entity or authority that took the additional final adverse legal action against you.

Provide details of another final adverse legal action imposed against you, if applicable.

Enter the date when the additional final adverse legal action was imposed.

Specify the entity or authority that took the additional final adverse legal action against you.

Check this box if you are enrolling for the sole purpose of ordering or certifying items and services for Medicare beneficiaries.

Enter your first name (print) for the certification statement and signature section.

Enter your middle initial for the certification statement and signature section.

Enter your last name (print) for the certification statement and signature section.

Enter any suffixes (e.g., Jr., Sr., M.D.) for the certification statement and signature section.

Provide your signature, including first, middle, last name, and any suffixes (e.g., Jr., Sr., M.D.).

Enter the ZIP Code + 4 for your primary practice location.

Enter the telephone number for your primary practice location.

Enter the fax number for your primary practice location, if applicable.

Enter the email address for your primary practice location, if applicable.

Enter the first name of the contact person (optional).

Enter the middle initial of the contact person.

Enter the last name of the contact person.

Enter any suffixes for the contact person (e.g., Jr., Sr., MD).

Enter the first line of the address for the contact person (P.O. Box or Street Name and Number).

Enter the second line of the address for the contact person (Suite, Room, Apt. #, etc.).

Enter the city or town for the contact person's address.

Enter the state for the contact person's address.

Enter the ZIP Code + 4 for the contact person's address.

Enter the telephone number for the contact person.

Enter the fax number for the contact person, if applicable.

Enter the email address for the contact person, if applicable.

Describe the relationship or affiliation of the contact person to you.

Check this box if you are changing the correspondence mailing address.

Enter the name of the business location.

Enter the attention line if applicable (optional).

Enter the first line of the mailing address (P.O. Box or Street Name and Number).

Enter the second line of the mailing address (Suite, Room, Apt. #, etc.).

Enter the city or town of the mailing address.

Enter the state of the mailing address.

Select this option if a DEA registration is not applicable to you.

Enter your DEA registration number.

Enter the effective date of your DEA registration in the format MM/DD/YYYY.

Enter the state where your DEA registration was issued.

Enter the name of the medical or other professional school you attended. If you are not an MD, enter the name of your training institution.

Enter the year you graduated from your medical or professional school in the format YYYY.

Enter the effective date in the format MM/DD/YYYY.

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by the Department of Veterans Affairs (DVA).

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by the Public Health Service (PHS).

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by the Department of Defense (DOD) or Tricare.

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by the Indian Health Service (IHS) or a Tribal Organization.

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by a Medicare-enrolled Federally Qualified Health Center (FQHC).

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by a Medicare-enrolled Rural Health Clinic (RHC).

Check this box if you are enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are employed by a Medicare-enrolled Critical Access Hospital (CAH).

Check this box if you are a physician enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are not employed by any entity in Group 1.

Check this box if you are an eligible professional enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are not employed by any entity in Group 1.

Check this box if you are a licensed resident enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are not employed by any entity in Group 1.

Check this box if you are a dentist enrolling in Medicare solely to order or certify items and services for Medicare beneficiaries and you are not employed by any entity in Group 1.

Check this box if you are currently enrolled solely to order or certify items and services for Medicare beneficiaries and you are updating your information.

Check this box if you are voluntarily withdrawing your Medicare enrollment to solely order or certify items and services for Medicare beneficiaries.

Indicate if you owe an existing debt to CMS by selecting 'Yes'.

Indicate if you do not owe an existing debt to CMS by selecting 'No'.

Select this option if a license is not applicable to you.

Enter your active license number.

Enter the effective date of your license in the format MM/DD/YYYY.

Enter the state where your license was issued.

Select this option if a certification is not applicable to you.

Enter your active certification number.

Enter the effective date of your certification in the format MM/DD/YYYY.

Enter the state where your certification was issued.

Enter the certifying entity, such as a specialty board, state, or other.

Specify your physician specialty if it is not listed in the provided options.

Specify your practitioner type if it is not listed in the provided options.

Check your primary physician specialty from the list. Only one specialty should be selected. Ensure you meet all federal and state requirements for the selected specialty.

Select this option if your primary specialty is Adult Congenital Heart Disease.

Select this option if your primary specialty is Advanced Heart Failure and Transplant Cardiology.

Select this option if your primary specialty is Allergy/Immunology.

Select this option if your primary specialty is Anesthesiology.

Select this option if your primary specialty is Cardiac Electrophysiology.

Select this option if your primary specialty is Cardiac Surgery.

Check this box if you are a Certified Nurse Midwife.

Check this box if you are a Clinical Nurse Specialist.

Check this box if you are a Clinical Psychologist.

Check this box if you are a Clinical Social Worker.

Check this box if you are a Nurse Practitioner.

Check this box if you are a Physician Assistant.

Check this box if your practitioner type is not listed among the predefined non-physician specialties.

Enter your first name as it appears on your social security record.

Enter your middle initial as it appears on your social security record.

Enter your last name as it appears on your social security record.

Enter any suffixes to your name, such as Jr., Sr., M.D., etc.

Enter any other first name you have used, if applicable.

Enter the middle initial of any other name you have used, if applicable.

Enter the last name of any other name you have used, if applicable.

Enter any suffixes to any other name you have used, such as Jr., Sr., M.D., etc.

Check this box if the other name you have used is a former or maiden name.

Check this box if the other name you have used is a professional name.

Check this box if the other name you have used does not fit into the predefined categories.

Enter your Social Security Number (S.S.N.).

Enter your date of birth in the format MM/DD/YYYY.

Enter your Medicare Identification Number (PTAN) if it has been issued to you.

Enter your National Provider Identifier (N.P.I.) for individual providers.

Select this option if your gender is male.

Select this option if your gender is female.

Check this box if your specialty is Undersea and Hyperbaric Medicine.

Check this box if your specialty is Urology.

Check this box if your specialty is Vascular Surgery.

Check this box if your specialty is not listed among the predefined physician specialties.

Indicate if you are a pediatrician not employed by any entity in Group 1.

Indicate if you are a retired physician who is still licensed.

Select this option if your professional status does not fit into the provided categories.

Select this checkbox if you are a physician specializing in Cardiovascular Disease (Cardiology).

Select this checkbox if you are a physician specializing in Colorectal Surgery (Proctology).

Select this checkbox if you are a physician specializing in Critical Care (Intensivists).

Select this checkbox if you are a Dentist.

Select this checkbox if you are a physician specializing in Dermatology.

Select this checkbox if you are a physician specializing in Diagnostic Radiology.

Select this checkbox if you are a physician specializing in Emergency Medicine.

Select this checkbox if you are a physician specializing in Endocrinology.

Select this checkbox if you are a physician specializing in Family Practice.

Select this checkbox if you are a physician specializing in Gastroenterology.

Select this checkbox if you are a physician specializing in General Practice.

Select this checkbox if you are a physician specializing in General Surgery.

Select this checkbox if you are a physician specializing in Geriatric Medicine.

Select this checkbox if you are a physician specializing in Geriatric Psychiatry.

Select this checkbox if you are a physician specializing in Gynecological Oncology.

Select this checkbox if you are a physician specializing in Hand Surgery.

Select this checkbox if you are a physician specializing in Hematology.

Select this checkbox if you are a physician specializing in Hematology/Oncology.

Select this checkbox if you are a physician specializing in Hematopoietic Cell Transplantation and Cellular Therapy.

Check this box if you specialize in Hospice or Palliative Care.

Check this box if you specialize as a Hospitalist.

Check this box if you specialize in Infectious Disease.

Check this box if you specialize in Internal Medicine.

Check this box if you specialize in Interventional Cardiology.

Check this box if you specialize in Interventional Pain Management.

Check this box if you specialize in Interventional Radiology.

Check this box if you specialize in Maxillofacial Surgery.

Check this box if you specialize in Medical Genetics and Genomics.

Check this box if you specialize in Medical Oncology.

Check this box if you specialize in Medical Toxicology.

Check this box if you specialize in Micrographic Dermatologic Surgery.

Check this box if you specialize in Nephrology.

Check this box if you specialize in Neurology.

Check this box if you specialize in Neuropsychiatry.

Check this box if you specialize in Neurosurgery.

Check this box if you specialize in Nuclear Medicine.

Check this box if you specialize in Obstetrics or Gynecology.

Check this box if you specialize in Ophthalmology.

Check this box if you specialize in Optometry.

Check this box if you are an Oral Surgeon and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are an Orthopedic Surgeon and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you practice Osteopathic Manipulative Medicine and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are an Otolaryngologist and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Pain Management and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are a Pathologist and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are a Pediatrician and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Peripheral Vascular Disease and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Physical Medicine and Rehabilitation and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are a Plastic and Reconstructive Surgeon and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are a Podiatrist and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Preventive Medicine and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are a Psychiatrist and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Pulmonary Disease and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Radiation Oncology and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Rheumatology and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Sleep Medicine and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Sports Medicine and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you specialize in Surgical Oncology and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Check this box if you are a Thoracic Surgeon and wish to enroll in the Medicare program for the purpose of ordering or certifying items and services for Medicare beneficiaries.

Enter the date when the form was signed. Use the format MM/DD/YYYY, where MM is the 2-digit month, DD is the 2-digit day, and YYYY is the 4-digit year.