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.
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Completed Form CMS-855I for a new physician applying for initial Medicare enrollment

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.
Categories: CAR forms, CMS forms, EDI enrollment forms, enrollment application forms, enrollment forms, Medicare application forms, Medicare enrollment forms, Medicare forms, physician application forms, physician enrollment forms, physician forms, practitioner application forms, practitioner forms, L.A. Care forms
Created: March 07, 2026 12:54 AM
Completed Form CMS-855I for a new physician applying for initial Medicare enrollment