If you are a physician’s assistant, did you fill in both your Medicare Identification Number (if issued) and your National Provider Identifier (NPI) on Page 4, Section 1A, in the two spaces provided within the first paragraph at the top of the page?

If you are reassigning all of your Medicare benefits (per section 4B1 of this application), did you furnish both your Medicare Identification Number (if issued) and your National Provider Identifier (NPI) on Page 4, Section 1A, in the two spaces provided within the second paragraph at the top of the page?

Did you check only one box on pages 4 & 5, Section 1A (Basic Information)?

Did you fill in the “required sections” denoted to the right side of the box you checked?

Did you check one or more boxes on Page 5, Section 1B (Basic Information)?

Did you fill in the “required sections” denoted to the right side of each box you checked?

Did you fill in your personal information on Page 6 in Section 2A, (Identifying Information), relative to yourself as well as to your license and certification information?

Did you provide your correspondence address (not a billing agency’s address) for Section 2B, on Page 6?

Note: This address cannot be your billing agency address.

Did you complete questions 1-4 in Section 2C (Resident/Fellow Status) on Page 7, if you are currently in an approved training program as a Resident or are in a Fellowship program?

If you are not in an approved training program, did you answer “no” to questions 1a and 1b?

Did you designate your primary specialty (only one) and your secondary specialties (one or more) on Page 8, Section 2D (Medical Specialties), Question 1.

If you checked Diagnostic Radiology as your specialty, and you will be billing Medicare for the technical component of the diagnostic tests, did you also complete a CMS-855B enrollment form as an Independent Diagnostic Testing Facility (IDTF)?

If applicable, did you designate your nonphysician specialty on Page 9, Section 2D, Question 2.

Note: Nonphysician practioners do not need to complete this section. An additional CMS-855I must be completed for each nonphysician specialty type.

If you are, or were, a physician’s assistant, did you fill in the required information on Page 10, Sections E, F and G?

Note: In Section 2E the employer’s and physician’s NPI must be listed. Additionally, ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. This includes any spacing or punctuation. If not, contact NPPES (https://nppes.cms.hhs.gov/NPPES/Welcome.do ) and request the update.

Did you respond “yes” or “no” regarding whether or not you hold a doctoral degree in Psychology in Section 2H on Page 11?

If you checked “yes,” did you provide a copy of your degree with this application?

Did you complete Section 2I (questions 1-4) on Page 11, if you are a psychologist billing independently.

Did you complete Section 2J (questions 1-5) on Page 11, if you are a physical or occupational therapist in private practice?

If you responded “yes” to any question numbered 2-5, did you attach a copy of the lease agreement for your facility usage?

Did you respond “yes” or “no” regarding whether or not you are an employee of a Medicare skilled nursing facility (SNF) or an employee of another entity that has an agreement to provide nursing services to a SNF in Section 2K on Page 11?

If you answered “yes,” did you provide the name and address of the applicable SNF?

Did you report any adverse legal actions that have been imposed against you in Section 3 (Adverse Legal Actions/Convictions) Page 13?

If yes, did you attach a copy of the adverse legal documentation and its resolution?

Note: Your application will be considered incomplete if the information is missing or you enter “not applicable.”

Did you complete Section 4A on Page 14, if you are the Sole Owner of a Professional Corporation, a Professional Association, or a Limited Liability Company intending to bill Medicare through this business entity?

Note: Section 4A – Ensure that the name corresponding with your NPI is your legal business name as reported to the IRS and that it matches exactly. If not, contact NPPES (https://nppes.cms.hhs.gov/NPPES/Welcome.do ) and request the update.

Has your organization, under any current or former name or business identity ever had any adverse legal actions that have been imposed against it (Page 14, Section 4 under “Adverse Legal History,” Questions 1 & 2)?

If yes, did you attach a copy of the adverse legal documentation and its resolution?

On Page 15, Section 4B, Questions 1 & 2, did you indicate (yes or no) that your services (all/any) will be rendered as part of a group or organization to which you will reassign your benefits?

If any or all of the services you render will be as part of a group or organization to which you will reassign your benefits, did you furnish the name(s), Medicare Identification Number(s) and NPIs of each group or organization?

Note: If all of your services will be rendered as part of a group and you will reassign your benefits, check yes in this section and proceed to section 13. If you check no, proceed with the application.

If any (meaning you work for a group and have an individual practice location) of your services will be rendered as part of a group and you will reassign your benefits, complete this section and proceed to section 4C.

Did you fill in the appropriate spaces in Section 4C (changes/additions/deletions) on Page 16 regarding your solo practice or your organization’s practice location(s)?

Note: If you as a sole practitioner or your organization sees patients in more than one location, complete this section for each location. The NPI in this section will be the NPI associated with you individual name and social security number.

Did you fill in the requested information on Page 17, Section 4D, for all locations where health care services are rendered in patients’ homes?

Did you fill in Section 4E on Page 18 regarding your option to have your special payment address mirror your practice location address, or to be different from that?

Note: For electronic fund transfer (EFT), include CMS-588 for initial enrollments and/or if you are making changes to an existing Medicare provider number that has not already been set up for EFT. Remember to include a voided check and/or deposit slip.

Did you provide your employer identification number (EIN) in Section 4F (Employer ID Number Information), Page 18 in order for your Medicare payments to be reported under your EIN?

Did you provide the storage facilities address where you maintain your medical records on Pages 19, Section 4G (if it’s different than your practice/physical location)?

Did you explain any unique circumstances concerning your practice locations or the method by which you render health care services in Section 4H on Page 19?

Did you include the name(s) of all owners, directors, partners and managing employees at any of your practice locations (practice locations were indicated previously in Section 4) on Page 20, Section 6A?

Note: If you have more than one owner, director, partner or managing employee, this section must be completed for each.

Did you identify any adverse legal actions that have been imposed against any owner, director, partner, or managing employee indicated above (Section 6B, Page 20)?

If yes, did you attach a copy of the adverse legal action documentation and resolution?

Did you complete Section 8 on Page 21 with information specific to the billing agency you utilize?

Note: If you do not use a billing agency, you can continue with Section 13 on Page 22). Make sure that you have first checked the box stating, “check here if this section does not apply.”

Did you complete Section 13 on page 22, with the contact person information?

Did you read Section 14 on pages 23 & 24 to ensure your understanding of the penalties for falsifying Medicare information?

Did you complete the Certification Statement in Section 15 (Page 26)?

Note: All signatures must be original. The use of blue ink is preferred.

Did you read Section 17 on page 27 to ensure that you have submitted correct and complete supporting documentation?

The following chart describes when and how FCSO will contact providers based on the contact information provided in your enrollment application.