Medicare Enrollment Application 855I. If you are changing information about a currently reported practice location or adding or removing practice location information, check the applicable box, furnish the effective date, and complete the appropriate fields Enrolling with another medicare administrative contractor (mac)
Many negative outcomes are directly tied to the amount of delayed medicare enrollment applications. The following forms can be used for initial enrollment, revalidations, changes in status, and voluntary termination: Application used by individual physicians or npps to initiate the medicare enrollment process or to change medicare enrollment information.