This form contains 514 fields organized into 117 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
3. Comments/Special Circumstances
3. Comments/Special Circumstances	Text	Provide an explanation of any unique circumstances concerning your practice location(s) or the method by which you render health care services.
Active Certification Status
Active Certification	Checkbox	Check this box if you have an active certification.
Not Applicable	Checkbox	Check this box if active certification information is not applicable to you.
Active License Status
Active License	Checkbox	Check this box if you have an active license.
Not Applicable	Checkbox	Check this box if the active license information is not applicable to your situation.
Acupuncture Service Provision
Acupuncture Service Provision Yes	Checkbox	Check this box if the physician provides acupuncture services and meets all state laws and requirements regarding such services.
Acupuncture Service Provision No	Checkbox	Check this box if the physician does not provide acupuncture services or does not meet all state laws and requirements regarding such services.
Acupuncture Services Inquiry
Acupuncture Services No	Checkbox	Check this box if the physician assistant, nurse practitioner, or clinical nurse specialist does not provide acupuncture services or does not meet the specified degree and licensing requirements. Fill only if 'Clinical Nurse Specialist (CNS)', 'Nurse Practitioner', 'Physician Assistant' is 'Yes' for any. Depends on: Clinical Nurse Specialist (CNS), Nurse Practitioner, Physician Assistant
Acupuncture Services Yes	Checkbox	Check this box if the physician assistant, nurse practitioner, or clinical nurse specialist provides acupuncture services and meets the specified degree and licensing requirements. Fill only if 'Clinical Nurse Specialist (CNS)', 'Nurse Practitioner', 'Physician Assistant' is 'Yes' for any. Depends on: Clinical Nurse Specialist (CNS), Nurse Practitioner, Physician Assistant
Adverse Legal Action History Confirmation
No - skip to section 4	Checkbox	Check this box if you have not had any final adverse legal action imposed against you and wish to skip to section 4.
Yes - continue below	Checkbox	Check this box if you have had a final adverse legal action imposed against you and need to provide further details.
Adverse Legal Action History Question
Adverse Legal Action History Yes	Checkbox	Check this box if your business has had a final adverse legal action imposed against it, and continue to the next part of the question.
Adverse Legal Action History No	Checkbox	Check this box if your business has NOT had a final adverse legal action imposed against it, and skip to Section 4.
Adverse Legal Action History Question: No	Checkbox	Check this box if the individual has not had a final adverse legal action imposed against them. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Adverse Legal Action History Question: Yes	Checkbox	Check this box if the individual has had a final adverse legal action imposed against them. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Billing Agency/Agent Address
Billing Agency/Agent Address Line 1	Text	Enter the primary street name and number for the billing agency/agent's address. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent Address Line 2	Text	Enter any additional address details such as suite, room, or apartment number for the billing agency/agent. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent City/Town	Text	Enter the city or town for the billing agency/agent's address. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent State	Text	Enter the state for the billing agency/agent's address. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent ZIP Code + 4	Text	Enter the five-digit ZIP code plus the four-digit extension for the billing agency/agent's address. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent Change Request
Billing Agency/Agent Change Request Effective Date	Date	Enter the effective date for the billing agency/agent change request. Fill only if 'Add', 'Remove', 'Change' is 'Yes' for any. Depends on: Change, Add, Remove
Add	Checkbox	Check this box if you are adding a billing agency/agent. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Remove	Checkbox	Check this box if you are removing a billing agency/agent. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Change	Checkbox	Check this box if you are changing information about your current billing agency/agent. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent Contact Information
Billing Agency/Agent Telephone Number	Text	Provide the telephone number for the billing agency or agent. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent Fax Number	Text	Provide the fax number for the billing agency or agent, if applicable. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent E-mail Address	Text	Provide the email address for the billing agency or agent, if applicable. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent Identification
Billing Agency/Agent Legal Name	Text	Enter the legal business name of the billing agency/agent as reported to the Internal Revenue Service, or the individual's name as reported to the Social Security Administration. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Individual Billing Agent Date of Birth	Date	Provide the date of birth for the individual billing agent. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent Tax ID or SSN	Text	Enter the billing agency's Tax Identification Number or the billing agent's Social Security Number. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Billing Agency/Agent DBA Name	Text	Enter the 'Doing Business As' (DBA) name of the billing agency/agent, if applicable. Fill only if 'Section 8 Does Not Apply' is 'No'. Depends on: Section 8 Does Not Apply
Business Entity Information
Legal Business Name	Text	Enter the legal business name as it is reported to the Internal Revenue Service.
Tax Identification Number	Text	Enter the Tax Identification Number (TIN) for the business entity.
Medicare Identification Number (PTAN)	Text	Enter the Medicare Identification Number (PTAN) if one has been issued to the business entity.
NPI (Type 2 - Organization)	Text	Enter the National Provider Identifier (NPI) for the business entity, which should be a Type 2 organization NPI.
Business Structure Information
Proprietary	Checkbox	Check this box if your business is registered with the IRS as a proprietary entity.
Non-Profit	Checkbox	Check this box if your business is registered with the IRS as a non-profit entity and you need to submit IRS Form 501(c)(3).
Disregarded Entity	Checkbox	Check this box if your business is registered with the IRS as a disregarded entity and you need to submit IRS Form 8832.
Certification Details
Certification Number	Text	Please provide the certification number for this active certification. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
Certification Effective Date	Date	Please provide the effective date of this certification. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
Certifying Entity	Text	Please provide the name of the entity that issued the certification, such as a specialty board or state. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
Certification State Issued	Text	Please provide the state where this certification was issued. If certified by a national entity, enter 'all'. Fill only if 'Active Certification' is 'Yes'. Depends on: Active Certification
Change Information
Medical Record Correspondence Change	Checkbox	Check this box if you are reporting a change to your Medical Record Correspondence Address. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence Effective Change Date	Date	Enter the date when the change to the Medical Record Correspondence Address becomes effective. Fill only if 'Medical Record Correspondence Same as 2D Address', 'Medical Record Correspondence Change' is 'No' and 'Change' is 'Yes'. Depends on: Medical Record Correspondence Same as 2D Address, Medical Record Correspondence Change
Compact License Status
Compact License Status: Yes	Checkbox	Check this box if the license is a compact license. Fill only if 'Active License' is 'Yes'. Depends on: Active License
Compact License Status: No	Checkbox	Check this box if the license is not a compact license. Fill only if 'Active License' is 'Yes'. Depends on: Active License
Contact Information
Telephone Number	Text	Please enter the telephone number.
Fax Number	Text	Please enter the fax number.
Email Address	Text	Please enter the email address.
Medical Record Correspondence Telephone Number	Text	Enter the telephone number for medical record correspondence. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence Fax Number	Text	Enter the fax number for medical record correspondence. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence E-mail Address	Text	Enter the email address for medical record correspondence. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Contact Person Action
Contact Person Action Effective Date	Date	Enter the effective date for the contact person action. Fill only if 'Add Contact Person', 'Change Contact Person' is 'Yes' for any. Depends on: Add Contact Person, Change Contact Person
Add Contact Person	Checkbox	Check this box if you need to add a new designated contact person.
Remove Contact Person	Checkbox	Check this box if you need to remove the designated contact person.
Change Contact Person	Checkbox	Check this box if you need to change the designated contact person information.
Contact Person Address
Contact Person Address Line 1	Text	Enter the first line of the contact person's address, including the street name and number. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Contact Person Address Line 2	Text	Enter the second line of the contact person's address, including suite, room, or apartment number. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
City/Town	Text	Enter the city or town for the contact person's address. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
State	Text	Enter the state for the contact person's address. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
ZIP Code + 4	Text	Enter the ZIP code, including the +4 extension, for the contact person's address. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Contact Person Contact Details
Contact Person Telephone Number	Text	Provide the telephone number for the contact person. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Contact Person Fax Number	Text	Provide the fax number for the contact person, if applicable. Fill only if 'Assign Contact Person' is 'No' and field is applicable. Depends on: Assign Contact Person
Contact Person Email Address	Text	Provide the email address for the contact person, if applicable. Fill only if 'Assign Contact Person' is 'No' and field is applicable. Depends on: Assign Contact Person
Contact Person Designation
Assign Contact Person	Checkbox	Check this box if you want to assign the individual listed in section 2A of this application as the designated contact person.
Contact Person Name
Contact Person First Name	Text	Enter the first name of the contact person. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Contact Person Middle Initial	Text	Enter the middle initial of the contact person. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Contact Person Last Name	Text	Enter the last name of the contact person. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Contact Person Suffix	Text	Enter any suffix for the contact person's name, such as Jr., Sr., MD, or other titles. Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Correspondence Mailing Address
Correspondence Mailing Address Attention	Text	Please provide the name of the person or department to whom the correspondence should be directed.
Correspondence Mailing Address Line 1	Text	Please enter the primary street address or P.O. Box for correspondence.
Correspondence Mailing Address Line 2	Text	Please enter any additional address details such as suite, room, or apartment number.
Correspondence Mailing Address City/Town	Text	Please enter the city or town for the correspondence mailing address.
Correspondence Mailing Address State	Text	Please enter the state for the correspondence mailing address.
Correspondence Mailing Address ZIP Code + 4	Text	Please enter the ZIP code, including the four-digit extension, for the correspondence mailing address.
Date Signed
Date Signed	Date	Provide the date this document was signed.
Delegated Official's Date Signed	Date	Provide the date the delegated or authorized official signed.
DEA Registration Details
DEA Registration Number	Text	Provide the Drug Enforcement Agency (DEA) registration number. Fill only if 'Active DEA Registration' is 'Yes'. Depends on: Active DEA Registration
DEA Effective Date	Date	Provide the effective date of the Drug Enforcement Agency (DEA) registration. Fill only if 'Active DEA Registration' is 'Yes'. Depends on: Active DEA Registration
DEA State Where Issued	Text	Provide the state where the Drug Enforcement Agency (DEA) registration was issued. Fill only if 'Active DEA Registration' is 'Yes'. Depends on: Active DEA Registration
DEA Registration Status
Active DEA Registration	Checkbox	Check this box if you have an active Drug Enforcement Agency registration.
Not Applicable	Checkbox	Check this box if Drug Enforcement Agency registration information is not applicable to you.
Delegated or Authorized Official's Name
Delegated or Authorized Official's First Name	Text	Enter the first name of the delegated or authorized official.
Delegated or Authorized Official's Middle Initial	Text	Enter the middle initial of the delegated or authorized official.
Delegated or Authorized Official's Last Name	Text	Enter the last name of the delegated or authorized official.
Delegated or Authorized Official's Suffix or Title	Text	Enter any applicable suffix or title for the delegated or authorized official, such as Jr., Sr., or M.D.
Doctoral Psychology Degree
Doctoral Psychology Degree Type	Text	Enter the type of your doctoral psychology degree, such as Ph.D., Ed.D., or Psy.D. Fill only if 'Psychologist, Clinical' is 'Yes'. Depends on: Psychologist, Clinical
Eighth Location
CITY/TOWN_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_8	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Electronic Storage Information
Site where electronic records are stored	Text	Depends on: 2. Electronic Storage. Do you store your patient medical records electronically? Yes
No	CheckBox	Depends on: D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B
2. Electronic Storage. Do you store your patient medical records electronically? Yes	CheckBox	Depends on: D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B
Eleventh Location
Eleventh Location City/Town	Text	Please provide the city or town for the eleventh location where healthcare services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Eleventh Location County	Text	Please provide the county for the eleventh location where healthcare services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Eleventh Location State/Territory	Text	Please provide the state or territory for the eleventh location where healthcare services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Eleventh Location ZIP Code	Text	Please provide the ZIP code for the eleventh location where healthcare services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Employee Relationship
Contracted Managing Employee	Checkbox	Check this box if the individual is a contracted managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
W-2 Managing Employee	Checkbox	Check this box if the individual is a W-2 managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Employer Identification Number
Employer Identification Number	Number	Provide the Employer Identification Number (EIN) for your business. Fill only if 'Pay under EIN' is 'Yes'. Depends on: Pay under EIN
Exclusive Use of Private Office Space
Exclusive Use of Private Office Space - No	Checkbox	Check this box if your private office space is not used exclusively for your private practice. Fill only if 'Yes, I maintain private office space' is 'Yes'. Depends on: Yes, I maintain private office space
Exclusive Use of Private Office Space - Yes	Checkbox	Check this box if your private office space is used exclusively for your private practice. Fill only if 'Yes, I maintain private office space' is 'Yes'. Depends on: Yes, I maintain private office space
Fifth Location
CITY/TOWN_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_5	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
First Final Adverse Legal Action
First Final Adverse Legal Action	Text	Enter the details of the first final adverse legal action. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
First Final Adverse Legal Action Date	Date	Enter the date when the first final adverse legal action occurred. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
First Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or the court/administrative body that imposed the first final adverse legal action. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
First Final Adverse Legal Action	Text	Enter the details of the first final adverse legal action. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
First Adverse Legal Action Date	Date	Enter the date the first final adverse legal action occurred. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
First Adverse Legal Action Taken By	Text	Enter the federal or state agency or the court/administrative body that imposed the first final adverse legal action. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
First Final Adverse Legal Action Row
First Final Adverse Legal Action	Text	Enter the details of the first final adverse legal action. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
First Final Adverse Legal Action Date	Date	Enter the date when the first final adverse legal action occurred. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
First Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or court/administrative body that took the first final adverse legal action. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
First Location
If services are only provided in selected cities/towns or counties, provide the locations below. Only list ZIP codes if you are not servicing the entire city/town or county. CITY/TOWN_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_1	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
First Location to Delete
First Deletion City/Town	Text	Enter the city or town for the first location to delete. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
First Deletion County	Text	Enter the county for the first location to delete. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
First Deletion State/Territory	Text	Enter the state or territory for the first location to delete. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
First Deletion ZIP Code	Text	Enter the ZIP code for the first location to delete. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
Fourth Location
CITY/TOWN_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_4	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Fourth Location to Delete
CITY/TOWN_Row_4	Text	Depends on: Deletion - Entire State
COUNTY_Row_4	Text	Depends on: Deletion - Entire State
STATE/TERRITORY_Row_4	Text	Depends on: Deletion - Entire State
ZIP CODE_Row_4	Text	Depends on: Deletion - Entire State
General
Storage Facility Address Line 1 (Street Name and Number)	Text
Storage Facility Address Line 2 (Suite, Room, Apt. #, etc.)	Text
Pracitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)	Signature
Delegated or Authorized Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)	Signature
Hospital/Facility Address
Hospital/Facility Name	Text	Enter the full name of the hospital or facility where you are a resident.
Hospital/Facility Street Address	Text	Enter the street address of the hospital or facility.
Hospital/Facility City	Text	Enter the city or town of the hospital or facility.
Hospital/Facility State	Text	Enter the state of the hospital or facility.
Hospital/Facility ZIP Code + 4	Text	Enter the ZIP Code and the optional +4 extension for the hospital or facility.
Individual Practitioner Receiving Reassigned Benefits Identification
Individual Practitioner Reassigned Benefits Effective Date	Date	Provide the effective date for the individual practitioner's reassigned benefits. Fill only if 'Terminate', 'Add', 'Change' is selected, any. Depends on: Terminate, Add, Change
Individual Practitioner First Name	Text	Enter the first name of the individual practitioner receiving reassigned benefits as reported to the Social Security Administration.
Individual Practitioner Middle Initial	Text	Enter the middle initial of the individual practitioner receiving reassigned benefits.
Individual Practitioner Last Name	Text	Enter the last name of the individual practitioner receiving reassigned benefits as reported to the Social Security Administration.
Individual Practitioner Suffix	Text	Enter any suffix for the individual practitioner, such as Jr., Sr., M.D., or other professional designation.
Social Security Number	CheckBox
Individual Practitioner Social Security Number	Text	Enter the Social Security Number (SSN) of the individual practitioner if applicable.
Employer Identitifcation Number (E.I.N.)	CheckBox
Individual Practitioner Employer Identification Number	Text	Enter the Employer Identification Number (EIN) for the individual practitioner if applicable, especially if they are a sole proprietor.
Individual Practitioner Medicare ID (PTAN)	Text	Enter the Medicare Identification Number (PTAN) for the individual practitioner if issued, or write 'pending' if the initial enrollment application is being submitted concurrently.
Individual Practitioner National Provider Identifier	Text	Enter the National Provider Identifier (NPI) for the individual practitioner.
Terminate	Checkbox	Check this box if the individual practitioner's reassigned benefits identification is being terminated.
Add	Checkbox	Check this box if a new reassignment of benefits identification is being added for the individual practitioner.
Change	Checkbox	Check this box if there is a change in the individual practitioner's reassigned benefits identification.
Initial Reporting State
specify the State	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state	CheckBox
License Details
Active License Number	Text	Provide the active license number. Fill only if 'Active License' is 'Yes'. Depends on: Active License
Active License Effective Date	Date	Provide the effective date of the active license. Fill only if 'Active License' is 'Yes'. Depends on: Active License
Active License State Issued	Text	Provide the state where the active license was issued. Fill only if 'Active License' is 'Yes'. Depends on: Active License
Mailing Address Change
Change Mailing Address	Checkbox	Check this box if you are reporting a change to your Correspondence Mailing Address.
Mailing Address Change Effective Date	Date	Enter the date when the mailing address change becomes effective. Fill only if 'Change Mailing Address' is 'Yes'. Depends on: Change Mailing Address
Maintain Private Office Space
No, I do not maintain private office space	Checkbox	Check this box if you do not maintain private office space.
Yes, I maintain private office space	Checkbox	Check this box if you maintain private office space.
Managing Employee Action
Managing Employee Effective Date	Date	Enter the effective date for the managing employee action. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Add Managing Employee	Checkbox	Check this box if you are adding a new managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Remove Managing Employee	Checkbox	Check this box if you are removing an existing managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Change Managing Employee	Checkbox	Check this box if you are changing information about your current managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Contact Information
Telephone Number	Text	Please enter the managing employee's telephone number. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Fax Number	Text	Please enter the managing employee's fax number, if applicable. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
E-mail Address	Text	Please enter the managing employee's email address. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Identification Numbers
Medicare Identification Number	Text	Enter the managing employee's Medicare Identification Number, if one has been issued. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
NPI	Text	Enter the managing employee's National Provider Identifier (NPI), if one has been issued. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Name
Managing Employee First Name	Text	Enter the first name of the managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Middle Initial	Text	Enter the middle initial of the managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Last Name	Text	Enter the last name of the managing employee. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Suffix/Title	Text	Enter any suffix or title for the managing employee, such as Jr., Sr., or M.D. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Personal Information
Social Security Number	Text	Provide the managing employee's Social Security Number. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Date of Birth	Date	Provide the managing employee's date of birth. Fill only if 'I am the managing employee' is 'No'. Depends on: I am the managing employee
Managing Employee Status
I am the managing employee	Checkbox	Check this box if you are the managing employee, which will allow you to skip to section 8.
Medical Record Correspondence Address
Medical Record Correspondence Attention	Text	Enter the name of the person or department to whose attention the medical record correspondence should be sent, if applicable. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence Address Line 1	Text	Enter the first line of the medical record correspondence address, including the P.O. Box or street name and number. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence Address Line 2	Text	Enter the second line of the medical record correspondence address, such as a suite, room, or apartment number, if applicable. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence City/Town	Text	Enter the city or town for the medical record correspondence address. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence State	Text	Enter the state for the medical record correspondence address. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence ZIP Code	Text	Enter the ZIP code and the optional plus four extension for the medical record correspondence address. Fill only if 'Medical Record Correspondence Same as 2D Address' is 'No'. Depends on: Medical Record Correspondence Same as 2D Address
Medical Record Correspondence Address Option
Medical Record Correspondence Same as 2D Address	Checkbox	Check this box if your Medical Record Correspondence should be mailed to the same address entered in section 2D, and then skip completing the rest of this section.
New Medicare Patient Acceptance
Accepting New Medicare Patients - Yes	Checkbox	Check this box if you are currently accepting new Medicare patients.
Accepting New Medicare Patients - No	Checkbox	Check this box if you are currently not accepting new Medicare patients.
Ninth Location
Ninth Location City/Town	Text	Enter the city or town for the ninth location where services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Ninth Location County	Text	Enter the county for the ninth location where services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Ninth Location State/Territory	Text	Enter the state or territory for the ninth location where services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Ninth Location Zip Code	Text	Enter the ZIP code for the ninth location where services are rendered. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Non-Physician Specialty Type
Anesthesiology Assistant	Checkbox	Check this box if your non-physician specialty type is Anesthesiology Assistant.
Certified Nurse Midwife (CNM)	Checkbox	Check this box if your non-physician specialty type is Certified Nurse Midwife (CNM).
Certified Registered Nurse Anesthetist (CRNA)	Checkbox	Check this box if your non-physician specialty type is Certified Registered Nurse Anesthetist (CRNA).
Clinical Nurse Specialist (CNS)	Checkbox	Check this box if your non-physician specialty type is Clinical Nurse Specialist (CNS).
Clinical Social Worker	Checkbox	Check this box if your non-physician specialty type is Clinical Social Worker.
Mass Immunization Roster Biller	Checkbox	Check this box if your non-physician specialty type is Mass Immunization Roster Biller.
Nurse Practitioner	Checkbox	Check this box if your non-physician specialty type is Nurse Practitioner.
Occupational Therapist in Private Practice	Checkbox	Check this box if your non-physician specialty type is Occupational Therapist in Private Practice.
Physical Therapist in Private Practice	Checkbox	Check this box if your non-physician specialty type is Physical Therapist in Private Practice.
Physician Assistant	Checkbox	Check this box if your non-physician specialty type is Physician Assistant.
Psychologist, Clinical	Checkbox	Check this box if your non-physician specialty type is Clinical Psychologist.
Psychologist Billing Independently	Checkbox	Check this box if your non-physician specialty type is Psychologist Billing Independently.
Qualified Audiologist	Checkbox	Check this box if your non-physician specialty type is Qualified Audiologist.
Qualified Speech Language Pathologist	Checkbox	Check this box if your non-physician specialty type is Qualified Speech Language Pathologist.
Registered Dietitian or Nutrition Professional	Checkbox	Check this box if your non-physician specialty type is Registered Dietitian or Nutrition Professional.
Undefined Non-Physician Practitioner Specialty	Checkbox	Check this box if your non-physician specialty type is not listed and falls under an Undefined Non-Physician Practitioner Specialty. Remember to specify the specialty in the provided field.
Undefined Non-Physician Specialty	Text	Please specify the undefined non-physician practitioner specialty type. Fill only if 'Undefined Non-Physician Practitioner Specialty' is 'Yes'. Depends on: Undefined Non-Physician Practitioner Specialty
Office Confinement in Institution
Office Confinement No	Checkbox	Check this box if your private practice office is not confined to a separately identified part of the institution/facility, or if it can be construed as extending throughout the entire institution/facility. Fill only if 'Practice Located in Institution or Facility: Yes' is 'Yes'. Depends on: Practice Located in Institution or Facility: Yes
Office Confinement Yes	Checkbox	Check this box if your private practice office is confined to a separately identified part of the institution/facility that is used solely as your office and cannot be construed as extending throughout the entire institution/facility. Fill only if 'Practice Located in Institution or Facility: Yes' is 'Yes'. Depends on: Practice Located in Institution or Facility: Yes
Organization/Group Receiving Reassigned Benefits Identification
Effective Date	Date	Enter the effective date for the reassignment or termination of benefits. Fill only if '2. Terminate', '2. Add', '2. Change' is selected, any. Depends on: 2. Terminate, 2. Add, 2. Change
Organization/Group Legal Business Name	Text	Provide the official legal business name of the organization or group as reported to the Internal Revenue Service.
Tax Identification Number (TIN)	Text	Enter the Tax Identification Number (TIN) for the organization or group.
Medicare Identification Number (PTAN)	Text	Provide the Medicare Identification Number (Provider Transaction Access Number or PTAN) if one has been issued to the organization or group.
National Provider Identifier (NPI)	Text	Enter the National Provider Identifier (NPI) for the organization or group.
2. Terminate	Checkbox	Check this box if the organization or group is terminating a currently established reassignment of benefits from an individual practitioner.
2. Add	Checkbox	Check this box if the organization or group is accepting a new reassignment of Medicare benefits from an individual practitioner.
2. Change	Checkbox	Check this box if the organization or group is making a change to existing reassignment of Medicare benefit information.
Other Facilities/Practice Locations Inquiry
Other Facilities/Practice Locations - Yes	Checkbox	Check this box if you render services at other facilities or practice locations.
Other Facilities/Practice Locations - No	Checkbox	Check this box if you do not render services at other facilities or practice locations.
Other Name
Other Name First Name	Text	Enter the first name for the other name.
Other Name Middle Initial	Text	Enter the middle initial for the other name.
Other Name Last Name	Text	Enter the last name for the other name.
Other Name Suffix/Title	Text	Enter any suffix, title, or other designation for the other name, such as Jr., Sr., or M.D.
Own, Lease, or Rent Private Office Space
Own, Lease, or Rent Private Office Space No	Checkbox	Check this box if you do not own, lease, or rent your private office space. Fill only if 'Yes, I maintain private office space' is 'Yes'. Depends on: Yes, I maintain private office space
Own, Lease, or Rent Private Office Space Yes	Checkbox	Check this box if you own, lease, or rent your private office space. Fill only if 'Yes, I maintain private office space' is 'Yes'. Depends on: Yes, I maintain private office space
Paper Storage Information
1. Name of Storage Facility	Text	Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
	Text	Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
City/Town	Text	Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
State	Text	Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
ZIP Code + 4	Text	Depends on: 1. Paper Storage. Do you store your patient medical records in a physical location? Yes
No	CheckBox	Depends on: D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B
1. Paper Storage. Do you store your patient medical records in a physical location? Yes	CheckBox	Depends on: D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B
Patient Treatment Inquiry
Treat Own Patients - No	Checkbox	Check this box if you do not treat your own patients. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Treat Own Patients - Yes	Checkbox	Check this box if you treat your own patients. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Payment Arrangement Selection
Pay under SSN	Checkbox	Check this box if you want your Medicare payments to be paid under your Social Security Number (SSN).
Pay under EIN	Checkbox	Check this box if you are a sole proprietor and want your Medicare payments to be paid under your Employer Identification Number (EIN).
Physician Specialty
G. Physician Specialty. Designate your primary specialty and all secondary specialty(s) below using: P=Primary S=Secondary. Addiction Medicine	Text	Max length: 1 characters
Adult Congenital Heart Disease	Text	Max length: 1 characters
Advanced Heart Failure and Transplant Cardiology	Text	Max length: 1 characters
Allergy/Immunology	Text	Max length: 1 characters
Anesthesiology	Text	Max length: 1 characters
Cardiac Electrophysiology	Text	Max length: 1 characters
Cardiac Surgery	Text	Max length: 1 characters
Cardiovascular Disease (Cardiology)	Text	Max length: 1 characters
Chiropractic	Text	Max length: 1 characters
Colorectal Surgery (Proctology)	Text	Max length: 1 characters
Critical Care Intensivists	Text	Max length: 1 characters
Dentist	Text	Max length: 1 characters
Dermatology	Text	Max length: 1 characters
Diagnostic Radiology	Text	Max length: 1 characters
Emergency Medicine	Text	Max length: 1 characters
Endocrinology	Text	Max length: 1 characters
Family Medicine	Text	Max length: 1 characters
Gastroenterology	Text	Max length: 1 characters
General Practice	Text	Max length: 1 characters
General Surgery	Text	Max length: 1 characters
Geriatric Medicine	Text	Max length: 1 characters
Geriatric Psychiatry	Text	Max length: 1 characters
Gynecological Oncology	Text	Max length: 1 characters
Hand Surgery	Text	Max length: 1 characters
Hematology	Text	Max length: 1 characters
Hematology/Oncology	Text	Max length: 1 characters
Hematopoietic Cell Transplantation and Cellular Therapy	Text	Max length: 1 characters
Hospice/Palliative Care	Text	Max length: 1 characters
Hospitalist	Text	Max length: 1 characters
Infectious Disease	Text	Max length: 1 characters
Internal Medicine	Text	Max length: 1 characters
Interventional Cardiology	Text	Max length: 1 characters
Interventional Pain Management	Text	Max length: 1 characters
Interventional Radiology	Text	Max length: 1 characters
Maxillofacial Surgery	Text	Max length: 1 characters
Medical Genetics and Genomics	Text	Max length: 1 characters
Medical Oncology	Text	Max length: 1 characters
Medical Toxicology	Text	Max length: 1 characters
Micrographic Dermatologic Surgery	Text	Max length: 1 characters
Nephrology	Text	Max length: 1 characters
Neurology	Text	Max length: 1 characters
Neuropsychiatry	Text	Max length: 1 characters
Neurosurgery	Text	Max length: 1 characters
Nuclear Medicine	Text	Max length: 1 characters
Obstetrics/Gynecology	Text	Max length: 1 characters
Ophthalmology	Text	Max length: 1 characters
Optometry	Text	Max length: 1 characters
Oral Surgery	Text	Max length: 1 characters
Orthopedic Surgery	Text	Max length: 1 characters
Osteopathic Manipulative Medicine	Text	Max length: 1 characters
Otolaryngology	Text	Max length: 1 characters
Pain Management	Text	Max length: 1 characters
Pathology	Text	Max length: 1 characters
Pediatric Medicine	Text	Max length: 1 characters
Peripheral Vascular Disease	Text	Max length: 1 characters
Physical Medicine and Rehabilitation	Text	Max length: 1 characters
Plastic and Reconstructive Surgery	Text	Max length: 1 characters
Podiatry	Text	Max length: 1 characters
Preventive Medicine	Text	Max length: 1 characters
Psychiatry	Text	Max length: 1 characters
Pulmonary Disease	Text	Max length: 1 characters
Radiation Oncology	Text	Max length: 1 characters
Rheumatology	Text	Max length: 1 characters
Sleep Medicine	Text	Max length: 1 characters
Sports Medicine	Text	Max length: 1 characters
Surgical Oncology	Text	Max length: 1 characters
Thoracic Surgery	Text	Max length: 1 characters
Undersea and Hyperbaric Medicine	Text	Max length: 1 characters
Urology	Text	Max length: 1 characters
Vascular Surgery	Text	Max length: 1 characters
Undefined Physician Specialty	Text	Max length: 1 characters
Undefined Physician Specialty	Text	Provide the specific name of the physician specialty if it is not listed among the predefined options. Fill only if 'Undefined Physician Specialty' is 'Yes'. Depends on: Undefined Physician Specialty
Practice and Reassignment Status
No Private Practice, All Benefits Reassigned	Checkbox	Check this box if you do not have a private practice but reassign all of your benefits to an organization/group or individual.
Private Practice, Any Benefits Reassigned	Checkbox	Check this box if you do have a private practice and also reassign any of your benefits to an organization/group or individual.
Private Practice, Services Only in Own Practice	Checkbox	Check this box if you do have a private practice and only render services in your own private practice.
Practice Located in Institution or Facility
Practice Located in Institution or Facility: No	Checkbox	Check this box if your private practice is NOT located in an institution or other facility.
Practice Located in Institution or Facility: Yes	Checkbox	Check this box if your private practice is located in an institution or other facility.
Practice Location Action
Effective date. 2 digit month, 2 digit day, 4 digit year	Text	Depends on: Add, B. Practice Location Information. If you are changing information about a currently reported practice location or adding or removing practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change, Remove
Add	CheckBox
B. Practice Location Information. If you are changing information about a currently reported practice location or adding or removing practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields in this section. Change	CheckBox
Remove	CheckBox
Practice Location Address
Practice Location Name (“Doing Business As” Name	Text
Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box	Text
Practice Location Street Address Line 2 (Suite, Room, Apt. #, etc	Text
City/Town	Text
State	Text
ZIP Code + 4	Text
Practice Location Contact Information
Telephone Number	Text
Fax Number (if applicable)	Text
E-mail Address (if applicable)	Text
Practice Location Medicare Information
Medicare Identification Number for this location – P.T.A.N. (if issued)	Text
Date you saw or will see your first Medicare patient at this practice location. 2 digit month, 2 digit day, 4 digit year	Text
Practice Locations Graduation Requirements
Practice Locations Part of Graduation Requirements Yes	Checkbox	Check this box if the services you render at the practice locations you are reporting are part of your requirements for graduation from a residency program.
Practice Locations Part of Graduation Requirements No	Checkbox	Check this box if the services you render at the practice locations you are reporting are not part of your requirements for graduation from a residency program.
Practitioner Signature
Practitioner First Name	Text	Provide the practitioner's first name as it should be printed for the signature.
Practitioner Middle Initial	Text	Provide the practitioner's middle initial.
Practitioner Last Name	Text	Provide the practitioner's last name as it should be printed for the signature.
Practitioner Suffix or Title	Text	Provide any applicable suffix (e.g., Jr., Sr.) or professional title (e.g., M.D.) for the practitioner.
Primary Practice Location
Primary Practice Location No	Checkbox	Check this box if this is not your primary practice location.
Primary Practice Location Yes	Checkbox	Check this box if this is your primary practice location.
Effective date. 2 digit month, 2 digit day, 4 digit year	Text	Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location Name	Text	Provide the name of the primary practice location, also known as the 'Doing Business As' name. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location Street Address Line 1	Text	Enter the primary practice location's street name and number, ensuring it is not a P.O. Box. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location Address Line 2	Text	Provide additional address details for the primary practice location, such as suite, room, or apartment number. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location City/Town	Text	Enter the city or town of the primary practice location. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location State	Text	Enter the state of the primary practice location. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location ZIP Code + 4	Text	Enter the 9-digit ZIP code for the primary practice location. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location Medicare ID (PTAN)	Text	Provide the Medicare Identification Number (PTAN) if issued for this primary practice location. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location National Provider Identifier (NPI)	Text	Enter the National Provider Identifier (NPI) for the primary practice location. Fill only if 'Primary Practice Location Remove', 'Primary Practice Location Change', 'Primary Practice Location Add' is checked, any. Depends on: Primary Practice Location Remove, Primary Practice Location Change, Primary Practice Location Add
Primary Practice Location Remove	Checkbox	Check this box if you are removing primary practice location information.
Primary Practice Location Change	Checkbox	Check this box if you are changing information about a currently reported primary practice location.
Primary Practice Location Add	Checkbox	Check this box if you are adding new primary practice location information.
Private Practice Location Type
Ambulatory Surgical Center	Checkbox	Check this box if your private practice location is an Ambulatory Surgical Center.
Business Office for Administrative/Telehealth Use Only	Checkbox	Check this box if your private practice location is a business office used exclusively for administrative or telehealth purposes.
Home Office for Administrative/Telehealth Use Only	Checkbox	Check this box if your private practice location is a home office used exclusively for administrative or telehealth purposes.
Hospital/Hospital Department	Checkbox	Check this box if your private practice location is a hospital or a hospital department.
Indian Health Services (IHS) or Tribal Facility	Checkbox	Check this box if your private practice location is an Indian Health Services (IHS) or a Tribal Facility.
Private Office Setting	Checkbox	Check this box if your private practice location is a private office setting.
Retirement or Assisted Living Community	Checkbox	Check this box if your private practice location is a retirement or assisted living community.
Skilled Nursing Facility or Other Nursing Facility	Checkbox	Check this box if your private practice location is a Skilled Nursing Facility or any other nursing facility.
Other Health Care Facility	Checkbox	Check this box if your private practice location is an other health care facility not listed and provide specification.
Other Health Care Facility Type	Text	Provide the specific type of other health care facility for your private practice location. Fill only if 'Other Health Care Facility' is 'Yes'. Depends on: Other Health Care Facility
Professional School Information
Professional School Name	Text	Enter the name of the medical or other professional school or training institution.
Graduation Year	Text	Enter the four-digit year of graduation from the professional school (YYYY).
Provide PT/OT Services Outside Office/Homes
5. No, do not provide PT/OT services outside office/homes	Checkbox	Check this box if you do not provide PT/OT services outside of your office and/or patients' homes.
5. Yes, provide PT/OT services outside office/homes	Checkbox	Check this box if you provide PT/OT services outside of your office and/or patients' homes.
Provider Identification Numbers
Medicare Identification Number (PTAN)	Text	Enter the Medicare Identification Number (PTAN) if one has been issued.
National Provider Identifier (NPI)	Text	Enter the National Provider Identifier (NPI) for the individual provider.
Provider Name
Provider First Name	Text	Enter the provider's first name exactly as it appears on their social security record.
Provider Middle Initial	Text	Enter the provider's middle initial exactly as it appears on their social security record.
Provider Last Name	Text	Enter the provider's last name exactly as it appears on their social security record.
Provider Suffix or Title	Text	Enter any suffix (e.g., Jr., Sr., III) or professional title (e.g., M.D., D.O., PhD) for the provider.
Reason for Submitting Application
New Enrollee in Medicare	Checkbox	Check this box if you are submitting this application because you are a new enrollee in Medicare.
Currently Enrolled to Enroll as Individual Practitioner	Checkbox	Check this box if you are currently enrolled in Medicare to order and certify, and you want to enroll as an Individual Practitioner.
Enrolling with another MAC	Checkbox	Check this box if you are submitting this application to enroll with another Medicare Administrative Contractor (MAC).
Revalidating Medicare Enrollment	Checkbox	Check this box if you are submitting this application to revalidate your Medicare enrollment.
Reactivating Medicare Enrollment	Checkbox	Check this box if you are submitting this application to reactivate your Medicare enrollment.
Reporting a Change	Checkbox	Check this box if you are submitting this application to report a change to your Medicare enrollment information, including establishing or terminating a reassignment.
Voluntarily Terminating Medicare Enrollment	Checkbox	Check this box if you are submitting this application to voluntarily terminate your Medicare enrollment.
Effective Date of Termination	Date	Enter the effective date when the Medicare enrollment is voluntarily terminated. Fill only if 'Voluntarily Terminating Medicare Enrollment' is 'Yes'. Depends on: Voluntarily Terminating Medicare Enrollment
Records Storage Location
D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B	CheckBox
Relationship to Individual or Organization/Group
Relationship to Individual or Organization/Group	Text	Provide the relationship or affiliation to the individual or organization/group (e.g., Spouse, Secretary, Attorney, Billing Agent). Fill only if 'Assign Contact Person' is 'No'. Depends on: Assign Contact Person
Remittance Address Change
Change	Checkbox	Check this box if you are reporting a change to your Remittance Notice/Special Payments Mailing Address.
Remittance Address Change Effective Date	Date	Enter the effective date for the remittance address change. Fill only if 'Change' is 'Yes'. Depends on: Change
Remittance/Special Payments Mailing Options
Mail to Practice Location Address	Checkbox	Check this box if remittance notices and special payments should be mailed to the practice location address specified in section 4B.
Mail to Correspondence Address	Checkbox	Check this box if remittance notices and special payments should be mailed to the correspondence address specified in section 2D.
Render PT/OT Services In Patients' Homes Only
1. Render PT/OT Services In Patients' Homes Only - No	Checkbox	Check this box if you do not ONLY render Physical Therapy (PT) or Occupational Therapy (OT) services in the patients' homes.
1. Render PT/OT Services In Patients' Homes Only - Yes	Checkbox	Check this box if you ONLY render Physical Therapy (PT) or Occupational Therapy (OT) services in the patients' homes.
Residency Program Graduation Information
Residency Program Completion Date	Date	Provide the date when the residency program was completed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if the services you render at the hospital/facility are NOT part of your requirements for graduation from a formal residency or program.
Yes	Checkbox	Check this box if the services you render at the hospital/facility are part of your requirements for graduation from a formal residency or program.
Right to Bill Directly
Right to Bill Directly - No	Checkbox	Check this box if you do not have the right to bill directly, and to collect and retain the fee for your services.
Right to Bill Directly - Yes	Checkbox	Check this box if you have the right to bill directly, and to collect and retain the fee for your services.
Second Final Adverse Legal Action
Second Final Adverse Legal Action	Text	Specify the details of the second final adverse legal action. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
Second Adverse Legal Action Date	Date	Enter the date when the second final adverse legal action occurred. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
Second Adverse Legal Action Taken By	Text	Enter the federal or state agency or court/administrative body that imposed the second final adverse legal action. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
Second Final Adverse Legal Action	Text	Provide a detailed description of the second final adverse legal action. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
Second Final Adverse Legal Action Date	Date	Enter the date when the second final adverse legal action occurred. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
Second Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or court/administrative body that imposed the second final adverse legal action. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
Second Final Adverse Legal Action Row
Second Final Adverse Legal Action	Text	Enter the details of the second final adverse legal action. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
Second Final Adverse Legal Action Date	Date	Enter the date when the second final adverse legal action occurred. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
Second Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or court/administrative body that imposed the second final adverse legal action. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
Second Location
CITY/TOWN_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_2	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Second Location to Delete
Second Deletion City/Town	Text	Provide the city or town for the second location to be deleted. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
Second Deletion County	Text	Provide the county for the second location to be deleted. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
Second Deletion State/Territory	Text	Provide the state or territory for the second location to be deleted. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
Second Deletion ZIP Code	Text	Provide the ZIP code for the second location to be deleted. Fill only if 'Deletion - Entire State' is 'No'. Depends on: Deletion - Entire State
Secondary Practice Location
Secondary Practice Location Effective Date	Date	Enter the effective date for the secondary practice location. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location Name	Text	Provide the 'Doing Business As' name for the secondary practice location. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location Street Address Line 1	Text	Enter the street name and number for the secondary practice location, ensuring it is not a P.O. Box. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location Address Line 2	Text	Provide additional address details such as suite, room, or apartment number for the secondary practice location. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location City	Text	Enter the city or town for the secondary practice location. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location State	Text	Enter the state for the secondary practice location. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location ZIP Code	Text	Enter the ZIP code for the secondary practice location, including the plus four extension if applicable. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location Medicare PTAN	Text	Provide the Medicare Identification Number (PTAN) for this secondary practice location, if issued. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Practice Location NPI	Text	Enter the National Provider Identifier (NPI) for the secondary practice location. Fill only if 'Secondary Remove', 'Secondary Change', 'Secondary Add' is checked, any. Depends on: Secondary Remove, Secondary Change, Secondary Add
Secondary Remove	Checkbox	Check this box if you are removing a secondary practice location.
Secondary Change	Checkbox	Check this box if you are changing information about a currently reported secondary practice location.
Secondary Add	Checkbox	Check this box if you are adding a new secondary practice location.
SECTION 4: BUSINESS INFORMATION (Continued) (2)
Change	Checkbox	Check this box if the information provided in this section regarding rendering services in patients' homes is a change from previously reported information.
Effective Date	Date	Enter the effective date. Fill only if 'Change' is 'Yes'. Depends on: Change
Section 8 Applicability
Section 8 Does Not Apply	Checkbox	Check this box if Section 8: Billing Agency/Agent Information does not apply to you, and you will skip to Section 12.
Service Responsibility Inquiry
Service Responsibility - Render Services Independently (No)	Checkbox	Check this box if you do not render services under your own responsibility, and are under the administrative control of an employer such as a physician, institution, or agency. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Service Responsibility - Render Services Independently (Yes)	Checkbox	Check this box if you render services under your own responsibility, free from the administrative control of an employer such as a physician, institution, or agency. Fill only if 'Psychologist Billing Independently' is 'Yes'. Depends on: Psychologist Billing Independently
Services Rendered to Outside Patients
Services Rendered to Outside Patients - No	Checkbox	Check this box if your private practice, located in an institution or facility, does not render services to patients from outside that institution or facility. Fill only if 'Practice Located in Institution or Facility: Yes' is 'Yes'. Depends on: Practice Located in Institution or Facility: Yes
Services Rendered to Outside Patients - Yes	Checkbox	Check this box if your private practice, located in an institution or facility, also renders services to patients from outside that institution or facility. Fill only if 'Practice Located in Institution or Facility: Yes' is 'Yes'. Depends on: Practice Located in Institution or Facility: Yes
Seventh Location
CITY/TOWN_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_7	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Sixth Location
CITY/TOWN_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_6	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Skilled Nursing Facility Details
Skilled Nursing Facility Name	Text	Enter the full legal name of the Skilled Nursing Facility. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
Skilled Nursing Facility Street Address Line 1	Text	Provide the first line of the Skilled Nursing Facility's street address, including the street name and number, ensuring it is not a P.O. Box. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
Skilled Nursing Facility Street Address Line 2	Text	Provide the second line of the Skilled Nursing Facility's street address, such as a suite, room, or apartment number, if applicable. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
City/Town	Text	Enter the city or town where the Skilled Nursing Facility is located. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
State	Text	Enter the state where the Skilled Nursing Facility is located. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
ZIP Code	Text	Enter the full ZIP Code for the Skilled Nursing Facility, including the plus four extension. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
Tax Identification Number of SNF	Text	Enter the Tax Identification Number (TIN) for the Skilled Nursing Facility. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
Telephone Number	Text	Enter the primary telephone number for the Skilled Nursing Facility. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
Fax Number	Text	Enter the fax number for the Skilled Nursing Facility, if applicable. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
E-mail Address	Text	Enter the E-mail address for the Skilled Nursing Facility, if applicable. Fill only if 'Skilled Nursing Facility Employment Status Yes' is 'Yes'. Depends on: Skilled Nursing Facility Employment Status Yes
Skilled Nursing Facility Employment Status
Skilled Nursing Facility Employment Status No	Checkbox	Check this box if you are not an employee of a skilled nursing facility (SNF) or of another entity that has an agreement to provide nursing services to a SNF.
Skilled Nursing Facility Employment Status Yes	Checkbox	Check this box if you are an employee of a skilled nursing facility (SNF) or of another entity that has an agreement to provide nursing services to a SNF.
Social Security Number and Date of Birth
Social Security Number	Text	Please enter the Social Security Number (SSN).
Date of Birth	Date	Please provide the date of birth.
Special Payments Mailing Address
Special Payments Address Line 1	Text	Enter the first line of the special payments mailing address, including P.O. Box or street name and number. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No', and if dependency field #2 is 'No'. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments Address Line 2	Text	Enter the second line of the special payments mailing address, including suite, room, or apartment number. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No', and if dependency field #2 is 'No'. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments City/Town	Text	Enter the city or town for the special payments mailing address. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No', and if dependency field #2 is 'No'. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments State	Text	Enter the state for the special payments mailing address. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No', and if dependency field #2 is 'No'. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
Special Payments ZIP Code + 4	Text	Enter the five-digit ZIP code followed by the four-digit extension for the special payments mailing address. Fill only if 'Mail to Practice Location Address', 'Mail to Correspondence Address' is 'No', and if dependency field #2 is 'No'. Depends on: Mail to Practice Location Address, Mail to Correspondence Address
State Deletion
Deletion - Entire State	Checkbox	Check this box if you are deleting an entire state.
Entire State of Deletion	Text	Enter the name of the entire state being deleted. Fill only if 'Deletion - Entire State' is 'Yes'. Depends on: Deletion - Entire State
Storage Location Action
Effective Date. 2 digit month, 2 digit day, 4 digit year	Text	Depends on: If you are adding or removing a storage location, check the applicable box below and furnish the effective date. Add, Remove
Remove	CheckBox	Depends on: D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B
If you are adding or removing a storage location, check the applicable box below and furnish the effective date. Add	CheckBox	Depends on: D. Medicare Beneficiary Medical Records storage address. Records are stored at the Practice Location reported in section 4B
Supporting Documentation Information
Copy of Final Adverse Legal Action Documentation	Checkbox	Check this box if you are submitting copy(s) of all final adverse legal action documentation, such as notifications, resolutions, and reinstatement letters.
Completed Form CMS-460 Agreement	Checkbox	Check this box if you are completing an initial enrollment or reactivation and wish to be a Participating Practitioner in Medicare, requiring the submission of Form CMS-460.
Completed Form CMS-588 Agreement	Checkbox	Check this box if you are submitting Form CMS-588 for electronic funds transfer authorization, unless you already receive electronic payments with no banking changes or are a physician/non-physician practitioner reassigning payments.
Bank Statement Waiving Right of Offset	Checkbox	Check this box if Medicare payments are sent to a financial institution with which you have a lending relationship, and you are providing a written statement from the bank waiving its right of offset for Medicare receivables.
IRS Confirmation of TIN and Legal Business Name	Checkbox	Check this box if you are submitting written confirmation from the IRS (e.g., Form CP-575) of your Tax Identification Number and Legal Business Name, especially if enrolling as a professional corporation, association, LLC, or sole proprietor with an EIN.
IRS Confirmation of LLC Disregarded Entity Status	Checkbox	Check this box if you are submitting written confirmation from the IRS (e.g., Form 8832) that your Limited Liability Company (LLC), including a single-member LLC, is classified as a Disregarded Entity.
Copy of IRS Determination Letter (Non-Profit)	Checkbox	Check this box if you are submitting a copy of your IRS Determination Letter (e.g., IRS Form 501(c)(3)) because you are registered as a non-profit organization.
Certification and Educational Requirements (Acupuncture)	Checkbox	Check this box if you are submitting a current copy of certification and proof of educational requirements because you are an eligible professional or non-physician specialty type providing acupuncture services.
Teaching Hospital/Facility Cost Agreement
Teaching Hospital/Facility Cost Agreement Yes	Checkbox	Check this box if the teaching hospital/facility has agreed to incur all or substantially all of the costs of your training in the non-hospital/facility location. Fill only if 'Practice Locations Part of Graduation Requirements Yes' is 'Yes'. Depends on: Practice Locations Part of Graduation Requirements Yes
Teaching Hospital/Facility Cost Agreement No	Checkbox	Check this box if the teaching hospital/facility has not agreed to incur all or substantially all of the costs of your training in the non-hospital/facility location. Fill only if 'Practice Locations Part of Graduation Requirements Yes' is 'Yes'. Depends on: Practice Locations Part of Graduation Requirements Yes
Tenth Location
Tenth Location City/Town	Text	Enter the city or town for the tenth location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Tenth Location County	Text	Enter the county for the tenth location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Tenth Location State/Territory	Text	Enter the state or territory for the tenth location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Tenth Location ZIP Code	Text	Enter the ZIP code for the tenth location. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Third Final Adverse Legal Action
Third Final Adverse Legal Action	Text	Enter the details of the third final adverse legal action. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
Third Action Date	Date	Enter the date the third final adverse legal action occurred. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
Third Action Taken By	Text	Enter the federal or state agency or court/administrative body that imposed the third final adverse legal action. Fill only if 'Yes - continue below' is 'Yes'. Depends on: Yes - continue below
Third Final Adverse Legal Action	Text	Enter the details of the third final adverse legal action. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
Third Final Adverse Legal Action Date	Date	Enter the date the third final adverse legal action occurred. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
Third Final Adverse Legal Action Taken By	Text	Enter the federal or state agency or court/administrative body that imposed the third final adverse legal action. Fill only if 'Adverse Legal Action History Yes' is 'Yes'. Depends on: Adverse Legal Action History Yes
Third Final Adverse Legal Action Row
Third Final Adverse Legal Action	Text	Enter the details of the third final adverse legal action. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
Third Final Adverse Legal Action Date	Date	Provide the date the third final adverse legal action occurred. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
Third Final Adverse Legal Action Taken By	Text	Enter the name of the entity or individual who took the third final adverse legal action. Fill only if 'Adverse Legal Action History Question: Yes' is 'Yes'. Depends on: Adverse Legal Action History Question: Yes
Third Location
CITY/TOWN_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
COUNTY_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
STATE/TERRITORY_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
ZIP CODE_Row_3	Text	Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Third Location to Delete
CITY/TOWN_Row_3	Text	Depends on: Deletion - Entire State
COUNTY_Row_3	Text	Depends on: Deletion - Entire State
STATE/TERRITORY_Row_3	Text	Depends on: Deletion - Entire State
ZIP CODE_Row_3	Text	Depends on: Deletion - Entire State
Twelfth Location
Twelfth Location City/Town	Text	Enter the city or town for the twelfth location where services are provided. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Location County	Text	Enter the county for the twelfth location where services are provided. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Location State/Territory	Text	Enter the state or territory for the twelfth location where services are provided. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Twelfth Location ZIP Code	Text	Enter the ZIP code for the twelfth location where services are provided. Fill only if '1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state' is 'No'. Depends on: 1. Initial Reporting and/or Additions. If you are reporting or adding an entire state, check the box below and specify the state
Type of Other Name
Former or Maiden Name	Checkbox	Check this box if the 'Other Name' provided is a former name or a maiden name.
Professional Name	Checkbox	Check this box if the 'Other Name' provided is a professional name.
Other Type of Name	Checkbox	Check this box if the 'Other Name' provided is of a type not listed as 'Former or Maiden Name' or 'Professional Name', and then describe it in the accompanying field.
Other Name Type Description	Text	Please describe the type of other name. Fill only if 'Other Type of Name' is 'Yes'. Depends on: Other Type of Name
What Information is Changing?
Personal Identifying Information	Checkbox	Check this box if you are changing personal identifying information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Final Adverse Legal Actions	Checkbox	Check this box if you are changing information related to final adverse legal actions. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Medical Specialty Information	Checkbox	Check this box if you are changing medical specialty information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Practitioner Specific Information	Checkbox	Check this box if you are changing practitioner specific information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Reassignment of Benefits Information	Checkbox	Check this box if you are changing reassignment of benefits information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Private Practice Business Information	Checkbox	Check this box if you are changing private practice business information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Managing Employee Information	Checkbox	Check this box if you are changing managing employee information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Address Information	Checkbox	Check this box if you are changing general address information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Correspondence Mailing Address	Checkbox	Check this box if you are changing your correspondence mailing address. Fill only if 'Address Information' is 'Yes'. Depends on: Address Information
Medical Record Correspondence Mailing Address	Checkbox	Check this box if you are changing your medical record correspondence mailing address. Fill only if 'Address Information' is 'Yes'. Depends on: Address Information
Remittance Notices/Special Payment Mailing Address	Checkbox	Check this box if you are changing your remittance notices or special payment mailing address. Fill only if 'Address Information' is 'Yes'. Depends on: Address Information
Medicare Beneficiary Medical Records Storage Address	Checkbox	Check this box if you are changing your Medicare beneficiary medical records storage address. Fill only if 'Address Information' is 'Yes'. Depends on: Address Information
Practice Location Address	Checkbox	Check this box if you are changing your practice location address. Fill only if 'Address Information' is 'Yes'. Depends on: Address Information
Billing Agency Information	Checkbox	Check this box if you are changing billing agency information. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change
Any other information not specified above	Checkbox	Check this box if you are changing any other information not specified in the list. Fill only if 'Reporting a Change' is 'Yes'. Depends on: Reporting a Change

Form CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners Instructions