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Cms 855b  Form

Cms 855b Form

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APPliCation Clinics/group Practices and Certain other Suppliers CMS-855B See Page 1 to deterMine if you are CoMPleting the CorreCt aPPliCation* See Page 2 for inforMation on where to Mail thiS aPPliCation* See Page 35 to find a liSt of the SuPPorting doCuMentation that MuSt Be SuBMitted with thiS aPPliCation* DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES Form Approved OMB NO. 0938-0685 who Should SuBMit thiS aPPliCation Clinics and group practices can apply for...
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