Step-By-Step Directions to Completing CMS-855R Application

August 6, 2007

Step-By-Step Directions To Completing CMS-855R Application

Section 1

Did you check only one box on Page 3 (Basic Information)?

• Yes

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

• Yes

Section 2

Did you provide the requested information for the supplier to whom benefits are being reassigned, or reassignment is being terminated.

• Yes

Did you denote “pending” in the Medicare identification number block on your application if the supplier’s initial enrollment application was submitted concurrently with this application?

• Yes

Note: The supplier’s name as reported to the IRS must match what was reported on the supplier’s CMS-855B when it enrolled. The NPI in this section is the NPI associated with the group.

Section 3

Did you complete all portions of this section?

• Yes

Did you denote “pending” in the Medicare Identification Number block on your application if your initial enrollment application is being submitted concurrently with this reassignment application?

• Yes

Note: The NPI in this section is the NPI associated with the individual who is reassigning benefits.

Section 4

Did the individual practitioner complete and sign (in ink) Section 4A on Page 5?

• Yes

Note: All signatures must be originals.

Did the authorized or delegated official complete and sign (in ink) Section 4B on Page 5?

• Yes

Note: All individuals who allow another supplier to receive payment for their services must sign the Reassignment of Benefits Statement. All signatures must be originals.

Section 7

Did you complete Section 7 (on page 6), with the Contact Person information?

• Yes

Your Application Contact Information

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

Contact Type	During the Enrollment Process	Once Provider/Supplier Is Enrolled
Contact Address	Used as a first contact for all for additional information requests.
Correspondence Address	Used for additional information requests if the contact information on the application is incomplete.
Pay-to Address	Used to send remittance to providers and or to notify groups and individual practitioner of approval/denial into the Medicare program.	Used to request additional claim information and or to send remittance advices and checks to providers. Note: Upon request from the provider/supplier, requests for additional claim information may be sent to the practice address.