Cms 855i form pdf 2026

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The document is the Medicare Enrollment Application (CMS-855I) for physicians and non-physician practitioners. It outlines the process for enrolling in the Medicare program, including eligibility criteria, required documentation, and instructions for completing and submitting the application. The application is necessary for healthcare providers who wish to bill Medicare for services rendered. It includes sections on personal information, practice location, managing employees, billing agency information, and penalties for providing false information.

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Click ‘Get Form’ to open the CMS 855I form in the editor.
Begin with Section 1, Basic Information. Fill in your Medicare Identification Number and National Provider Identifier (NPI) as required.
Proceed to Section 2, Identifying Information. Enter personal details such as your name, date of birth, and social security number. Ensure all information matches your official records.
In Section 3, provide details about any final adverse legal actions or convictions if applicable. This section is crucial for compliance.
Move to Section 4, Practice Location Information. List all practice locations where you will render services to Medicare beneficiaries.
Complete Sections 5 through 15 as applicable, ensuring that all required fields are filled accurately.
Finally, review your entries for accuracy and completeness before submitting the application through our platform.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (53 Votes)
2011	4.4 Satisfied (228 Votes)

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