Ambulance Suppliers: Enrollment Requirements

Published 02/08/2018

The Medicare enrollment (CMS-855) application is used to collect information about you and to secure the necessary documentation to ensure you are qualified and eligible to enroll in the Medicare program. It is also used to update any changes you have made, including changes of address. Ambulance suppliers must use the Medicare Enrollment Application form (CMS-855B) to enroll or to change existing enrollment information.

As a reminder, when you have more than one location, you must notify Palmetto GBA of each location by completing section 4 of the CMS-855B application for established suppliers and new enrollees. It is your responsibility to report all locations within the jurisdiction of the Medicare fee-for-service contractor to which you have submitted or will submit your application. You must provide the specific street address as recorded by the United States Postal Service. P.O. Boxes are not acceptable.

If you have locations in another Medicare fee-for-service contractor’s jurisdiction, complete a separate enrollment application (CMS-855B) for those locations and submit it to the Medicare fee-for-service contractor that has jurisdiction over those locations.

Note: For advance life support (ALS), the vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle.

For additional information on the CMS-855 applications and instructions on completing the CMS 855 applications, download the appropriate CMS 855 form from the Enrollment Application Finder tool.


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