Cms855i: Fill out & sign online

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Click ‘Get Form’ to open the cms855i 2006 form in the editor.
Begin with Section 1, Basic Information. Clearly indicate your reason for submitting the application by checking the appropriate box and completing the required sections.
Proceed to Section 2, Identifying Information. Fill in your personal details accurately, ensuring that your name and Social Security number match official records.
In Section 3, Adverse Legal Actions/Convictions, disclose any relevant legal history as required. If none apply, simply select 'No' and move on.
Complete Section 4 regarding Practice Location Information. Provide specific addresses where you will render services and ensure all details are accurate.
Review Sections 5 through 17 for any additional information required based on your specific situation. Attach necessary supporting documents as indicated.
Finally, sign the Certification Statement in Section 15 to confirm that all information is true and complete before submitting your application.

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