Form CMS-855A Medicare Enrollment Application 2025

1. Click ‘Get Form’ to open the CMS-855A application in our editor.
2. Begin by completing Section 1, which requires basic information about your organization and the reason for submitting the application. Ensure you check the appropriate box indicating whether you are a new enrollee or making changes.
3. In Section 2, provide identifying information such as your Legal Business Name, Tax Identification Number (TIN), and National Provider Identifier (NPI). Make sure this information matches what is on file with the IRS.
4. Proceed to Section 3 to report any final adverse legal actions that may affect your eligibility. This section must be filled out completely if applicable.
5. Fill out Section 4 with details of all practice locations where services will be provided. Include specific addresses and indicate if they are primary locations.
6. Complete Sections 5 and 6 regarding ownership interests and managing control information, ensuring all individuals and organizations with significant ownership are reported accurately.
7. Attach any required supporting documentation as outlined in Section 17 before submitting your application through our platform for processing.

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