Electronic CMS 855 Forms Available
Electronic and print versions of five Medicare Provider/Supplier Enrollment forms
can be obtained from the Website of the Centers for Medicare & Medicaid Services
(CMS) at http://www.cms.hhs.gov/MedicareProviderSupEnroll/
. (By selecting this link, you will leave the WPS Medicare Website.)
The forms are:
- Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries (CMS 855A)
- Application for Health Care Providers that will Bill Medicare Carriers (CMS 855B)
- Application for Individual Health Care Practitioners (CMS 855I)
- Application for Individual Reassignment of Benefits (CMS 855R)
- Application for DMEPOS Suppliers (CMS 855S) [Note: DMERCS must notify the National Supplier Clearinghouse (NSC) of all address changes.]
The CMS 855 is the required form for provider and supplier enrollment in the Medicare program. The forms are used for applying for a Medicare provider number, changing information in an existing Medicare enrollment record, and reassigning Medicare benefits. To change information, providers and suppliers should complete only the first section of the form and those sections that reflect the changes, additions, or deletions.
With the change to the new Form CMS 855, the 1/98 Form HCFA 855C (Change of Information Request) became obsolete. All change requests must be submitted on the appropriate Form CMS 855 with a signed and dated certification statement.
Applications for Wisconsin, Illinois, Michigan, and Minnesota should be sent to the provider enrollment unit for each state:
Wisconsin, Illinois, Michigan
WPS Medicare Provider Enrollment Unit
P.O. Box 8248
Madison, WI 53708-8248
OR
1707 West Broadway
Madison, WI 53713-1834
Phone: (877) 908-8476
Fax: (608) 301-2740
Minnesota
WPS Medicare Provider Enrollment Dept.
8120 Penn Ave. South, Ste. 200
Bloomington, MN 55431-1394
Phone: (866) 564-0315
FAX: (952) 885-2814
Page Last Updated: Monday, 09-Jun-2008 13:34:30 CDT
