Create your 855i Application Form from scratch
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Here's how it works
01. Start with a blank 855i Application Form
Open the blank document in the editor, set the document view, and add extra pages if applicable.
02. Add and configure fillable fields
Use the top toolbar to insert fields like text and signature boxes, radio buttons, checkboxes, and more. Assign users to fields.
03. Distribute your form
Share your 855i Application Form in seconds via email or a link. You can also download it, export it, or print it out.
A detailed guide on how to craft your 855i Application Form online
Step 1: Start with DocHub's free trial.
Visit the DocHub website and sign up for the free trial. This provides access to every feature you’ll need to create your 855i Application Form without any upfront cost.
Step 2: Navigate to your dashboard.
Sign in to your DocHub account and navigate to the dashboard.
Step 3: Initiate a new document.
Hit New Document in your dashboard, and choose Create Blank Document to craft your 855i Application Form from scratch.
Step 4: Use editing tools.
Place different elements such as text boxes, radio buttons, icons, signatures, etc. Organize these fields to suit the layout of your form and assign them to recipients if needed.
Step 5: Modify the form layout.
Rearrange your form quickly by adding, moving, deleting, or combining pages with just a few clicks.
Step 6: Set up the 855i Application Form template.
Transform your newly designed form into a template if you need to send multiple copies of the same document numerous times.
Step 7: Save, export, or share the form.
Send the form via email, share a public link, or even post it online if you wish to collect responses from a broader audience.
Got questions?
We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.
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Is 855R being discontinued?
After November 1, 2023, MACs will return any newly submitted CMS-855I and CMS-855R applications on the previous versions to the provider/supplier with a letter explaining that the CMS-855I has been updated and the CMS-855R discontinued and the current version of the CMS-855I (05/23) must be submitted.
What is the difference between CMS risk and HHS risk adjustment?
The HHS-HCC is a risk adjustment model that calculates risk scores concurrently, which means it uses diagnoses from a period to predict costs in that same period. This model is primarily used for commercial payers of the Affordable Care Act (ACA) and is not restricted to older patients, which the CMS-HCC is.
What is the Medicare 855I form for?
All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.
What is the difference between 855I and 855O?
CMS-855I: For employed physician assistants (sections 1, 2, 3, 13, and 15). CMS-855R: Individuals reassigning (entire application). CMS-855O: All eligible physicians and non-physician practitioners (entire application). Same applications are required as those of new enrollees.
What is the CMS-855R application form?
The CMS-855R application is used by individual physicians and non-physician practitioners (hereafter collectively referred to as individual practitioners) who want to reassign their right to receive Medicare payments to another eligible individual or entity (i.e., sole proprietorship/clinic/group practice/other
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Related Q&A to 855i Application Form
What is the difference between participating and nonparticipating providers?
Non-participating providers, sometimes referred to as out-of-network providers, do not have formal contracts with any particular insurance network, in contrast to participating providers. Rather, they are autonomous entities that set their own prices for healthcare services.
What is the difference between CMS 855B and 855I?
The difference between enrolling a practice using an 855I and 855B is the reporting of ownership information. When one individual owns the whole practice, Medicare can utilize the 855I to verify that the owner meets Medicare requirements.
What is a CMS-855I?
❖ 855I. CMS form which enrolls physicians and non-physician practitioners who. render Medicare Part B services to beneficiaries. Enrolls practitioners who are the sole owner of a professional corporation. and bill Medicare through this business entity.
