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Cms 855i Form: What You Should Know

Homeopaths. • Chiropractor's and Osteopathic Physicians. • Acupuncturists. • Optometrists. • Chiropractors. • Psychiatrists. • Family Practice, Clinical and Community Health Practitioners. • Nurse practitioners ➢ Medicare Fee-for-Service beneficiaries. Note: The form has six pages. There are two forms for initial payment and two for renewal of enrollment. You will be required to complete all six pages of the form. If you do not complete all six pages, your enrollment will be deferred. (There may be a fee for submission of this form if it is required.) If you are unable to complete the form on the six pages, you can also download the additional forms needed for each page. Do not write on the form in any location other than the area marked with an X. This is not considered completed, but the form is returned to the vendor (or you) to be revalidated. If you wish to have someone submit the application for you, you will have the option of using a third party administrator (also known as a “HVAC contractor”)  To do so, select the “Provider Enrollment” check box. Select all and press the “Submit” button. Do not check the boxes “Provider” and “HVAC” at the same time. You will not be able to select this option until you have checked one of these two boxes. In our example, the “Provider” box will be checked by the HVAC company, so we would have to select this option. ➢ Choose “HVAC Services Provider”. If you select this option, you will be able to print the enrollment form to complete your own enrollment. You will save the file to your computer and fax it to the vendor to complete the enrollment process. (Vendor may require a minimum fee of 5 in some cases). Please do not fax out of your mail slot, it will not have the same effect on your enrollment. However, faxing a completed application to the vendor does not have the same effect as the completed form being printed out and sent. Note: After the receipt of an application, CMS will not accept additional enrollment documents.

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