A. Is the ambulance an air ambulance? Yes No
B. Does the ambulance company lease air craft from another company? Yes No
C. Does the ambulance have an arrangement with the Paramedic Intercept Service? Yes No
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17 CMS 855B form (CMS Web site) Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted. Complete Attachment 1 (Ambulance Service Suppliers) in the 8555B form. Include the following documents: State Ambulance license (if applicable) State Business license (if applicable) A copy of lease agreement IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee. A written statement (signed by the President, CEO, or CFO of the airport from where the aircraft is hangared) giving the name and address of the facility and proof that the company possesses a valid charter flight license (FAA 135 certificate). A copy of the signed contract(s) between the ambulance and the Paramedic Intercept Services Electronic Funds Transfer (EFT) EFT CMS 588 form (CMS Web site) A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter. Submitting Claims Electronically - Electronic Data Interchange (EDI) There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act). New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below: JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Be sure to: Complete all required information, including any boxes to indicate “not applicable.” Include effective date in all appropriate sections, for example, section 4b, “Practice Information.” Provide information required for Electronic Fund Transfer. Sign your application in BLUE ink. Date your application. Submit copies of all appropriate licenses, agreements and tax documents. Important Information: Ambulances and Mass Immunization Billers must accept assignment on all of their Medicare claims; Palmetto GBA will automatically establish these two suppliers in the Medicare Participation program. Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request. Required documentation must be submitted with the initial application(s); not doing so results in delayed processing. Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov
JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190
Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306
Be sure to:
Important Information:
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17 CMS 855B form (CMS Web site) Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted. Complete Attachment 1 (Ambulance Service Suppliers) in the 8555B form. Include the following documents: State Ambulance license (if applicable) State Business license (if applicable) A copy of lease agreement IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee. A written statement (signed by the President, CEO, or CFO of the airport from where the aircraft is hangared) giving the name and address of the facility and proof that the company possesses a valid charter flight license (FAA 135 certificate). Electronic Funds Transfer (EFT) EFT CMS 588 form (CMS Web site) A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter. Submitting Claims Electronically - Electronic Data Interchange (EDI) There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act). New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below: JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Be sure to: Complete all required information, including any boxes to indicate “not applicable.” Include effective date in all appropriate sections, for example, section 4b, “Practice Information.” Provide information required for Electronic Fund Transfer. Sign your application in BLUE ink. Date your application. Submit copies of all appropriate licenses, agreements and tax documents. Important Information: Ambulances and Mass Immunization Billers must accept assignment on all of their Medicare claims; Palmetto GBA will automatically establish these two suppliers in the Medicare Participation program. Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request. Required documentation must be submitted with the initial application(s); not doing so results in delayed processing. Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
C. Does this ambulance company have an arrangement with the Paramedic Intercept Service? Yes No
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17 CMS 855B form (CMS Web site) Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted. Complete Attachment 1 (Ambulance Service Suppliers) in the 8555B form. Include the following documents: State Ambulance license (if applicable) State Business license (if applicable) IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee. A written statement (signed by the President, CEO, or CFO of the airport from where the aircraft is hangared) giving the name and address of the facility and proof that the company possesses a valid charter flight license (FAA 135 certificate). A copy of the signed contract(s) between the ambulance and the Paramedic Intercept Services Electronic Funds Transfer (EFT) EFT CMS 588 form (CMS Web site) A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter. Submitting Claims Electronically - Electronic Data Interchange (EDI) There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act). New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below: JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Be sure to: Complete all required information, including any boxes to indicate “not applicable.” Include effective date in all appropriate sections, for example, section 4b, “Practice Information.” Provide information required for Electronic Fund Transfer. Sign your application in BLUE ink. Date your application. Submit copies of all appropriate licenses, agreements and tax documents. Important Information: Ambulances and Mass Immunization Billers must accept assignment on all of their Medicare claims; Palmetto GBA will automatically establish these two suppliers in the Medicare Participation program. Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request. Required documentation must be submitted with the initial application(s); not doing so results in delayed processing. Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17 CMS 855B form (CMS Web site) Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted. Complete Attachment 1 (Ambulance Service Suppliers) in the 8555B form. Include the following documents: State Ambulance license (if applicable) State Business license (if applicable) IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee. A written statement (signed by the President, CEO, or CFO of the airport from where the aircraft is hangared) giving the name and address of the facility and proof that the company possesses a valid charter flight license (FAA 135 certificate). Electronic Funds Transfer (EFT) EFT CMS 588 form (CMS Web site) A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter. Submitting Claims Electronically - Electronic Data Interchange (EDI) There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act). New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below: JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Be sure to: Complete all required information, including any boxes to indicate “not applicable.” Include effective date in all appropriate sections, for example, section 4b, “Practice Information.” Provide information required for Electronic Fund Transfer. Sign your application in BLUE ink. Date your application. Submit copies of all appropriate licenses, agreements and tax documents. Important Information: Ambulances and Mass Immunization Billers must accept assignment on all of their Medicare claims; Palmetto GBA will automatically establish these two suppliers in the Medicare Participation program. Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request. Required documentation must be submitted with the initial application(s); not doing so results in delayed processing. Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
B. Does this ambulance have an arrangement with a Paramedic Intercept Service? Yes No
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17 CMS 855B form (CMS Web site) Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted. Complete Attachment 1 (Ambulance Service Suppliers) in the 8555B form. Include the following documents: State Ambulance license (if applicable) State Business license (if applicable) IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee. A copy of the signed contract(s) between the ambulance and the Paramedic Intercept Services Electronic Funds Transfer (EFT) EFT CMS 588 form (CMS Web site) A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter. Submitting Claims Electronically - Electronic Data Interchange (EDI) There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act). New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below: JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Be sure to: Complete all required information, including any boxes to indicate “not applicable.” Include effective date in all appropriate sections, for example, section 4b, “Practice Information.” Provide information required for Electronic Fund Transfer. Sign your application in BLUE ink. Date your application. Submit copies of all appropriate licenses, agreements and tax documents. Important Information: Ambulances and Mass Immunization Billers must accept assignment on all of their Medicare claims; Palmetto GBA will automatically establish these two suppliers in the Medicare Participation program. Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request. Required documentation must be submitted with the initial application(s); not doing so results in delayed processing. Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov Complete form 855B sections 1-6, 8, 13, 15 16 (optional), and 17 CMS 855B form (CMS Web site) Section 15 (Certification Statement) of the 855B must be signed and dated by the 'authorized official' for initial enrollment. Faxed, photocopied, or stamped signatures will not be accepted. Complete Attachment 1 (Ambulance Service Suppliers) in the 8555B form. Include the following documents: State Ambulance license (if applicable) State Business license (if applicable) IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee. Electronic Funds Transfer (EFT) EFT CMS 588 form (CMS Web site) A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter. Submitting Claims Electronically - Electronic Data Interchange (EDI) There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act). New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin. Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below: JM Mailing Address JJ Mailing Address Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728 Be sure to: Complete all required information, including any boxes to indicate “not applicable.” Include effective date in all appropriate sections, for example, section 4b, “Practice Information.” Provide information required for Electronic Fund Transfer. Sign your application in BLUE ink. Date your application. Submit copies of all appropriate licenses, agreements and tax documents. Important Information: Ambulances and Mass Immunization Billers must accept assignment on all of their Medicare claims; Palmetto GBA will automatically establish these two suppliers in the Medicare Participation program. Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request. Required documentation must be submitted with the initial application(s); not doing so results in delayed processing. Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.
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