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Cms 855b  Form

Cms 855b Form

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Medicare Administrative Contractor MAC under this tax identification number. MEDICARE ENROLLMENT APPLICATION Clinics/Group Practices and Other Suppliers CMS-855B SEE PAGE 1 2 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION* SEE PAGE 3 FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION* SEE SECTION 12 FOR A LIST OF SUPPORTING DOCUMENTATION TO BE SUBMITTED WITH THIS APPLICATION* TO VIEW YOUR CURRENT MEDICARE ENROLLMENT RECORD GO TO HTTPS //PECOS*CMS*HHS*GOV DEPARTMENT OF...
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