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Printed Date: 9/22/2015
The following sections of the 855S require addresses:
Section 2A- Physical Address of the Business
The address must be a specific street as recorded by the United States Postal Service. Do not furnish a P.O. Box.
Section 4A- 1099 Mailing Address
Furnish the address where the IRS 1099 Form should be mailed.
Section 4B- Correspondence Mailing Address
This is the address where correspondence will be sent to the supplier by the NSC or other Medicare Administrative Contractor.
Section 4C- Revalidation Request Package Mailing Address
This is the address where the NSC will send the supplier's enrollment revalidation package. Suppliers may also opt in this section to have the revalidation package mailed to the physical location of the business or to the correspondence address.
Section 4C- Remittance Notices/Special Payments Mailing Address
This is the address where all other payment information such as remittance notices and non-routine special payments should be sent by the DME Medicare Administrative Contractor. Suppliers may also opt in this section to have remittance notices and non-routine special payments mailed to the physical location of the business or to the correspondence address.
Section 4E- Medicare Beneficiary Medical Records Storage Address
Furnish the physical address where the Medicare beneficiaries’ medical records are stored if the address is different than the Business Location address. Do not furnish a P.O. Box or drop box. Suppliers may select the same physical address as indicated for the business location.
This information is also required when submitting information via Internet-based PECOS.
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Last Updated: 12/04/2018