CMS-855I is to be used by Physicians and non-physician practitioners (including clinical psychologists) — Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
• An individual practitioner who will provide services in a private setting.
• An individual practitioner who will provide services in a group setting. If you plan to render all of your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17 of this application.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for- service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you have added or changed a practice location).
• An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you are the sole owner.
• If you provide services in a group/organization setting, you will also need to complete a separate application, the CMS-855R, to reassign your benefits to each organization. If you terminate your association with an organization, use the CMS-855R to submit that change.
All physicians, as well as all non-physician practitioners listed below, must complete this application to initiate the enrollment process:
• Anesthesiology Assistant
• Audiologist
• Certified nurse midwife
• Certified registered nurse anesthetist
• Clinical nurse specialist
• Clinical social worker
• Mass immunization roster biller
• Occupational therapist in private practice
• Physical therapist in private practice
• Physician assistant
• Psychologist, Clinical
• Psychologist billing independently
• Registered Dietitian or Nutrition Professional
• Speech Language Pathologist
