What is the CMS 855A form?
The CMS 855A form is the Medicare Federal Health Care Provider/Supplier Enrollment application. Medicare Part A providers who are either entering the Medicare program for the first time or currently enrolled will use this form.

Who must complete the CMS 855A application?
Medicare Part A providers entering the Medicare program or any existing Medicare certified provider undergoing Changes of Ownership, Intermediary, management, address, contact personnel, or other information.

Where can I request the CMS 855A?
You can now obtain an electronic version of the CMS 855A via the Internet at the following web site: http://www.cms.hhs.gov/MedicareProviderSupEnroll/03_EnrollmentForms.asp. Alternatively, request one from the Fiscal Intermediary:

Part A Provider Enrollment
C/O Provider Audit & Reimbursement
P O Box 1418
Little Rock, AR 72203
Telephone Number: 501-918-7462

Please contact the state agency to obtain any additional forms you may need. You may request information for Skilled Nursing Facilities from Sophie Fraser, Licensure & Certification Section, P O Box 8059 Slot 404, Little Rock, AR 72203-8059, telephone number 501-682-8424. You may contact Sharon Martin to obtain information relating to hospitals and other Part A facilities, at Health Facility Services, 5800 West 10th Street Suite 400, Little Rock, AR 72204, telephone number 501-661-2201.

What additional information must be submitted with the CMS 855A form? Please make sure that you submit all required licenses, IRS documentation, sales agreement, transfer agreement, Articles of Incorporation, EDI agreement, Form HCFA 588, and if applicable, the billing agency/management agreement. Any additional information that you may feel necessary may be sent as well.

Am I provider-based?
There are several requirements that must be met before a facility is considered to be provider-based. If you believe that your facility is provider-based, please review 42CFR Section 413.65 or 413.174 for ESRD facilities. Also please see section relating to Provider-Based Status Definitions.

What is an IRS Form CP575?
The IRS Form CP575 is the IRS generated letter you receive from the IRS granting your Employer Identification Number.

Who is considered a managing/directing employee?
A managing/directing employee is generally defined as any employee who has day-to-

day control over the organization, including hiring and firing capacity. Examples, would include, but are not limited to, administrator, director, chief financial officer, chief operating officer, chief executive officer, and Board of Directors. Examples of those which would probably not qualify are director of nursing (unless this individual's responsibility includes managing the staff), and medical director (unless this individual has the ability to hire and fire employees, as well). Ultimately, each applicant must decide which individuals meet these criteria. A good basic rule is to include any individual, which you believe may qualify as a managing/directing employee.

Who should be listed as the contact person?
The contact person should be the person at your organization who is responsible for ensuring that your facility completes the Provider Enrollment process and who can answer any questions about information on the application. Please note that if the application must be returned for additional information, it will be returned to the individual listed in this section.

If there are multiple answers for certain sections, must you make a copy of that section for each response?
You may submit those multiple answers in any manner you wish as long as the information from all of the required fields is present.

How does a Part A Provider get set up for Electronic Funds Transfer (EFT)?
Complete the 855A, Section 4F for Electronically Funds Transfer and submit Form HCFA-588 along with the 855A.