Helpful Tips

CMS-855O Completion Tips for Physicians or Eligible Professionals for the Sole Purpose of Ordering, Certifying or Prescribing Part D Drugs

CMS-855O is a national enrollment; providers who relocate to another state are not required to disenroll in the current state and reenroll in the new state to order and refer only. If new licenses and/or certifications are obtained or current enrollment information must be updated as a result of relocation, send the change of information CMS-855O application to the MAC which processed your initial application. Please review the original approval letter to determine the MAC who processed your order and refer enrollment.

Note:

  • License must be effective prior to application receipt.
  • Per MLN Matters Article SE18008 Provider Enrollment - Unlicensed Resident, must submit one of the following:
    • A residency contract signed and dated by both an official of the institution and the resident physician
    • A letter, on institution letterhead, confirming the applicant’s status as a resident physician signed and dated by an official of the institution and containing at a minimum the name of the applicant.

Follow the instructions printed on the CMS-855O application.

Section Completion Tips
Section 1: Basic Information 1A – Select reason for submitting application, complete sections as instructed.

1B – Select one reason from Group 1 or Group 2.

Note: If applicant is an unlicensed resident, select other and specify.
Section 2: Identifying Information 2A –Enter all personal information.
  • The full legal name reported must match the social security record and NPPES Registry exactly including any initials, credentials and suffixes.
2B – Enter educational information.

2C – Enter License/Certification/ DEA information or mark “not applicable” when appropriate.
Section 3: Adverse Legal Action/Convictions Section must be answered and only a “yes” or “no” response is acceptable.
  • If there are no final adverse legal actions, convictions, exclusions, revocations, or suspensions, be sure to check the box labeled No.
  • If there are any actions whether under the current or a former name, check the box labeled Yes and list details and attach final adverse legal action documentation and/or resolutions.
Section 4: Medical Specialty Information Complete 4A – for physician specialty or 4B – for eligible professional or other nonphysician specialty type.
Section 5: Correspondence Mailing Address Indicate Business Location name where provider will be ordering and referring.  Contact information must be where NGS can reach applicant directly and can be provider’s home and personnel information.
Section 6: Contact Information (Optional) Complete with the contact person’s information.
Section 8: Certification Statement Complete with individual physician or eligible professional name as indicated in section 2A. The individual physician or eligible professional must sign and date.

 

Reviewed 7/29/2024