Medicare Enrollment Application-For Eligible Ordering And Referring Physicians And Non-Physician Practitioners {CMS-855O}

CMS-855O - MEDICARE ENROLLMENT APPLICATION ENROLLMENT FOR ELIGIBLE ORDERING/CERTIFYING PHYSICIANS AND OTHER ELIGIBLE PROFESSIONALS. Physicians and eligible professionals can apply to enroll for the sole purpose of ordering or certifying items and/or services to beneficiaries in the Medicare program, or make a change in their ordering/certifying enrollment information. Most physicians and eligible professionals (as defined in section 1848(k)(3)(B) of the Social Security Act) enroll in the Medicare program to be reimbursed for the covered services they furnish to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, CMS requires certain physicians and eligible professionals to enroll in the Medicare program for the sole purpose of ordering/certifying items or services for Medicare beneficiaries. These physicians and eligible professionals do not and will not send claims to a Medicare Administrative Contractor (MAC) for the services they furnish. The physicians and eligible professionals who may enroll in Medicare solely for the purpose of ordering/certifying include, but are not limited to, those who are: • Employed by the Department of Veterans Affairs (DVA) • Employed by the Department of Defense (DOD)/Tricare (moved from list below so the first two bullets are military related while the rest of the bullets are from HHS (ASPE)) • Employed by the Public Health Service (PHS) • Employed by the Indian Health Service (IHS) or a Tribal Organization • Employed by Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) or Critical Access Hospitals (CAH) • Licensed Residents (as defined in 42 C.F.R. section 413.75(b)) in an approved medical residency program • Dentists, including oral surgeons • Pediatricians • Retired physicians who are licensed Once enrolled, you will be listed on a CMS database and will be deemed eligible to order/certify services and items for Medicare beneficiaries. The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. See the last page of this application to read the Privacy Act Statement. www.FormsWorkflow.com