Cms 855i form pdf 2025

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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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Where can I find CMS forms?

Hard copy forms may be available from Intermediaries, Carriers, State Agencies, local Social Security Offices or End Stage Renal Disease Networks that service your State.

Is the CMS 855R being discontinued?

Starting November 1, 2023, you must use the revised form. Form updates: Combines the CMS-855I and CMS-855R paper applications and discontinues the CMS-855R. Removes physician assistant employer arrangements.

What is a CMS 855I form?

❖ 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.

What is the difference between 855B and 855I?

CMS Form 855I Used to enroll individual practitioners (e.g., MDs, DOs, NPs, PAs) in Medicare. CMS Form 855B Used to enroll a group practice or clinic entity. CMS Form 855R Used to reassign a providers Medicare benefits to a group thats already enrolled.

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