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Printed Date: 9/22/2015
Address Sections on the CMS-855B Enrollment Application
Section 2 B3, Correspondence Address: The correspondence address must be one where the Medicare Administrative Contractor (MAC) can directly contact the applicant to resolve any issues once the provider or supplier is enrolled in the Medicare program. The address can be a P.O. Box or, in the case of an individual practitioner, a person’s home address may be used. The address cannot belong to a billing agency, management services organization, chain home office or the provider’s representative (e.g., attorney, financial advisor, etc.). When submitting enrollment information, providers can request that written correspondence (including appeal letters) be sent to the practice location.
Section 4 A, Practice Location Address: Report all practice locations where services will be furnished. If there is more than one location, copy and complete this section for each. Please list your primary practice location first. Post office boxes are not acceptable.
Section 4 B, Remittance Notices or Special Payments Mailing Address: Since payment will be made by EFT, the special payments address will indicate where all other payment information (e.g., remittance notices, special payments) is sent.
Section 4 C, Patients’ Medical Records Address: If you store patients’ medical records (current and/or former patients) at a location other than the location in Section 4A or 4E, complete this section with the address of the storage location. Post office boxes and drop boxes are not acceptable.
Section 4 E, Base of Operations Address for Mobile or Portable Suppliers (Location of Business Office or Dispatcher/Scheduler): The base of operations is the location from where personnel are dispatched, where mobile/portable equipment is stored, and, when applicable, where vehicles are parked when not in use.
Section 5 A, Ownership/Managing Control Organization Address
Section 8, Billing Agency Address
Section 13, Contact Person Address: If questions arise during the processing of this application, the fee-for-service contractor will contact the individual shown in this section.
Attachment 2 E, Independent Diagnostic Testing Facilities (IDTF): Other supervisor sites — If the supervising physician provides supervision for any other IDTF, provide the information requested, including the address.
NOTE: It is vitally important that providers pick the correct address for appeals correspondence. Appeal letters include private information about Medicare beneficiaries. It is considered a Protected Health Information (PHI) violation if the letter is returned by someone because it went to the wrong address. Providers should ensure that the address they choose (pay-to address or practice address) is the correct one for handling appeal decisions. Providers can choose to receive letters via eServices. This prevents PHI exposure.
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Last Updated: 12/31/2020
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