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Attachment for Section 2C- Information for Each Additional

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The document is an application attachment for the U.S. Department of the Treasury's State Small Business Credit Initiative, specifically Section 2C, which requires applicants to provide information about additional programs and the amounts requested for each program.

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What is an 855B application?

What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.

Is 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.

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.

Who completes a 855B?

Complete and submit this application if you are an organization/group that plans to bill Medicare and you are: A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).

How do I submit CMS 855A?

Send this completed application with original signatures and all required documentation to your designated MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.

What is the difference between 855I and 855B?

CMS-855B: For group (all applicable sections). CMS-855I: For reassigning individuals who are new to the Medicare program, or not PECOS enrolled (sections 1, 2, 3, 4B, 13, and 15). CMS-855I: For employed physician assistants (sections 1, 2, 3, 13, and 15) CMS-855R: Individuals reassigning (entire application).

What is a Medicare 855B?

Form # CMS 855B. Form Title. Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers. Revision Date.

What is the definition of change of ownership in CMS?

Change of Ownership (CHOW) is defined in 42 CFR 489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law.

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