Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners Completed Form Examples and Samples
Explore comprehensive examples and samples of a completed Form CMS-855I, the Medicare Enrollment Application for Physicians and Non-Physician Practitioners. Our filled-out templates guide you through initial enrollment, revalidation, and updates, making the Medicare application process clearer.
Form CMS-855I Example – New Physician Initial Enrollment
How this form was filled:
This example shows a completed Form CMS-855I for Dr. Emily Carter, a family medicine physician seeking initial enrollment in the Medicare program. Key sections filled include personal identifying information (Section 2), practice location details (Section 4), and billing information for a solo practitioner. The application is signed and dated for submission in early 2026.
Information used to fill out the document:
- Application Type: Initial Enrollment
- Practitioner Name: Dr. Emily R. Carter, M.D.
- Social Security Number: XXX-XX-1234 (Actual SSN required on form)
- National Provider Identifier (NPI): 1234567890
- Date of Birth: 06/15/1990
- Medical School: Stanford University School of Medicine
- Graduation Year: 2020
- License Number: MD-98765
- License State: California
- Original License Date: 07/01/2024
- Specialty: Family Medicine (30)
- Practice Name: Redwood Family Health
- Practice Address: 456 Oak Avenue, Suite 100, Sacramento, CA 95814
- Practice Phone: (916) 555-0101
- Correspondence Address: Same as Practice Address
- Signature: Emily R. Carter
- Date Signed: 01/10/2026
What this filled form sample shows:
- Clearly completed Section 2: Identifying Information for an individual physician.
- Accurate entry of Section 3: Final Adverse Legal Action Information (reporting no adverse history).
- Detailed completion of Section 4: Practice Location Information for a single office.
- Correctly filled Section 8: Billing Information for a practitioner billing directly.
- Properly signed and dated certification statement in Section 15.
Form specifications and details:
| Form Name: | Form CMS-855I |
| Form Title: | Medicare Enrollment Application for Physicians and Non-Physician Practitioners |
| Agency: | Centers for Medicare & Medicaid Services (CMS) |
| Use Case: | Initial enrollment for a new physician starting a private practice. |
Created: March 07, 2026 12:54 AM
