Helpful Tips

CMS-855I Completion Tips for Physicians and NPPs in Private Practice (Sole Owner or Sole Proprietor) Revalidation Application

Follow the instructions printed on the CMS-855I application and refer to this list of sections required for revalidation.

Section Required for Revalidation General Guidelines
Section 1:
Basic Information		 1A – Select ‘You are Revalidating your Medicare Enrollment,’

1B – Check all that apply (optional during revalidation)
Section 2:
Personal Identifying Information		 2A – Enter all personal information
  • The full legal name reported must match the social security records and NPPES Registry exactly including any initials, credentials and suffixes
2B – Check the box not applicable or supply the active license/certification/registration information

2C – Indicate if accepting new patients (optional)

2D – Indicate an address where correspondence will be sent directly to physician or nonphysician practitioner
  • Can be a home address, but cannot be a billing agency or medical management company
2E – Indicate an address where medical records correspondence will be sent directly to physician or nonphysician practitioner
  • Cannot be a billing agency or medical management company information
2G – Specify physician specialty (select all that apply)
  • Use “P” for primary and “S” for all secondary

2H – Specify nonphysician practitioner specialty

2I1 – Identify doctoral psychology degree

2I2 – Psychologists billing independently (in private practice)

2J - Physical/Occupational Therapists (in private practice) 

2K – If a nurse practitioner or certified clinical nurse specialist answers “yes”, furnish SNF information
Section 3:
Final Adverse Legal Action		 Section must be answered and only a “yes” or “no” response is acceptable
  • If there are no final adverse legal actions, convictions, exclusions, revocation, or suspensions, be sure to check the box labeled ‘No’
  • If there are any actions whether under the current or a former name or business identity, check the box labeled ‘Yes’ and list details and attach final adverse legal action documentation and/or resolutions
Section 4:
Business Information		 Check appropriate box:
  • If you do have a private practice and you also reassign any of your benefits to an entity, check this box and complete sections 4A – 4F (Sole Owner).
  • If you do have a private practice and only render services in your own private practice, check this box and complete sections 4A-4E (Sole Proprietor).
4A – Identify business structure for private practice

4A1-4A2 – If individual has a professional corporation, professional association, limited liability company, etc.
  • The legal business name must match the NPPES Registry and the IRS document exactly, including any suffix, i.e., PC, PA, LLC, etc.
4A3 – If a sole proprietor/sole proprietorship

4B – Identify every office, clinic, hospital, assisted living community, SNF or any other health facility where you will be rendering services including NPI/PTAN combinations

4C – Check applicable box or enter remittance notices/special payments mailing address for the private practice

4D – Check applicable box or complete medical records storage information

4E – Complete if rendering services in patients’ homes

4F – Complete for every group or organization where benefits have been reassigned
  • Specify each group/organization’s name, PTAN and NPI
  • Be sure to address all reassignments specified in the revalidation request letter
Section 6:
Managing Employee Information
  • Copy appropriate page as many times as necessary.
  • Check the box “I am the managing employee” or complete 6A and 6B for each managing employee.
Section 8:
Billing Agency Information
  • Check the box if section does not apply or complete with billing agency information.
Section 12: Supporting Documentation Information
  • Contains a list of supporting documentation.
  • Remember to include the CMS-588 (EFT) form and a confirmation of account information on bank letterhead or a voided check.
Section 13:
Contact Person Information (optional)
  • Complete with each contact person’s information.
Section 15:
Certification Statement and Signature
  • Complete with individual physician or nonphysician practitioner’s name as indicated in section 2A for section 15B.
  • The individual physician or nonphysician practitioner must sign and date.
  • If adding a new reassignment, the authorized/delegated official must sign and date section 15C.

Related Content

Revised 7/29/2024