The 855I Form is an IRS form that is used to request an extension of time to file. This form can be used by individuals or businesses, and can be filed online or by mail. The 855I Form must be filed before the original tax return deadline in order to receive an extension. Extensions are available for both individual and business tax returns, but filing a extension does not extend the time to pay any taxes that may be owed. Additional information on extensions can be found on the IRS website.
| Question | Answer |
|---|---|
| Form Name | 855I Form |
| Form Length | 4 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min |
| Other names | 855i application online, 855i form, fillable 855i, form 855i form |
Physicians and
General
Reminders
•Section 1A - All individual Medicare identification numbers (PTANs) to be revalidated are required to be identified with NPI in the upper portion of this section; check revalidation box.
•Section 3.1 - If “Yes,” Section 3.2 must be completed. “See Attached” is not acceptable.
•Section 4B - All association information is required to be completed for all entities/groups that individual is revalidating enrollment with (for each PTAN identified in Section 1A).
•Section 13 - Include an email address and fax number.
•Section 15 - Original and dated signature of individual identified in Section 2 of the application.
Physicians & NPPs (excluding PAs)
Required Sections:
• Section 1A . . . |
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• Section 3 |
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• Section 13 . . . |
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• Section 2* . . . |
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• Section 4B |
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• Section 15 . . . |
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Have you completed each of the required sections? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . The
in Section 4B of the individual physician’s/NPP’s
Physician Assistants
Required Sections: |
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• Section 1A . . . |
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• Section 3 |
. . . |
• Section 15 . . . |
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• Section 2* . . . |
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• Section 13 |
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Have you completed each of the required sections? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* Physician Assistants continue to Attachments checklist.
Sole Owners
CMS 855I: Physician &
Reminders
•Section 1A - All individual Medicare identification numbers (PTANs) to be revalidated are required to be identified with NPI in the upper portion of this section; check revalidation box.
•Section 3.1 - If “Yes,” Section 3.2 must be completed. “See Attached” is not acceptable.
•Section 4A - Entity’s legal business name, tax identification number, entity’s PTAN, and incorporation information. All questions on this page are required to be answered.
•Section 4C - Entire section required for all practice locations (including entity PTAN & NPI), date (mm/dd/yyyy) you saw first Medicare patient is required.
•Section 13 - Include an email address and fax number.
•Section 15 - Original and dated signature of individual identified in Section 2 of the application.
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Physicians and
Required Sections: |
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• Section 1A |
. . . |
• Section 4A . . . |
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• Section 8 |
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• Section 2* |
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• Section 4C . . . |
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• Section 13 |
. . . |
• Section 3 |
. . . |
• Section 4E . . . |
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• Section 15 |
. . . |
Have you completed each of the required sections? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* Continue to attachments checklist.
Sole Proprietors
CMS 855I: Physician &
Reminders
•Section 1A - All individual Medicare identification numbers (PTANs) to be revalidated are required to be identified with NPI in the upper portion of this section; check revalidation box.
•Section 3.1 - If “Yes,” Section 3.2 must be completed. “See Attached” is not acceptable.
•Section 4B - All association information is required to be completed for all entities/groups that the individual is revalidating (each PTAN identified in Section 1A).
•Section 4C - Required to be completed entirely for all practice locations (including entity PTAN & NPI).
•Section 4F - Unless EIN is reported in this section, payments will be made to individual’s social security number.
•Section 13 - Original and dated signature of individual identified in Section 2 of the application.
•Section 15 - Original and dated signature of individual identified in Section 2 of the application.
Required Sections: |
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• Section 1A |
. . . |
• Section 4C . . . |
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• Section 8 |
. . . |
• Section 2* |
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• Section 4E . . . |
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• Section 13 |
. . . |
• Section 3 |
. . . |
• Section 4F . . . |
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• Section 15 |
. . . |
• Section 4B |
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Have you completed each of the required sections? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
* Continue to attachments checklist.
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Physicians and
CMS 855I Section 2
Reminders
•Section 2A, 2B, 2C - Apply to ALL 855I application processes and must be completed in its entirety.
•Section 2E - Physician Assistants establishing employment arrangement(s).
•Section 2F - Physician Assistants terminating employment arrangement(s).
•Section 2G - Sole owners and sole proprietors terminating physician assistant’s employment arrangement.
•Section 2D1, 2D2 - Type of provider specialty is required.
•Section 2H, 2K - Reassignments, sole owners, and sole proprietors complete if applicable to provider type identified in section 2D2.
•Section 2I, 2J - Sole owners and sole proprietors complete if applicable to provider type identified in Section 2D2.
•Section 2L - Sole owner’s entity or sole proprietor furnishing technical component of ADI services.
CMS 855R: Reassignment of Medicare Benefits for Terminations
Physician &
Reminders
•Section 1 - Effective date (mm/dd/yy) is required.
•Section 2 - Legal business name as reported to IRS, tax identification number, entity/group Medicare number (PTAN), entity/group NPI. For each tax identification number you are reassigned to, a separate
•Section 3 - Individual’s name (as identified on 855I application), social security number, individual’s Medicare identification number (PTAN) (all that are identified in Section 1A of 855I application).
•Section 4A - Required to be originally signed and dated by individual identified in Section 3 of 855R and Section 2 of 855I applications; or,
•Section 4B - Required to be originally signed and dated by authorized/delegated official of the entity identified in Section 2 of this application.
•Section 7 - Contact person information is required (include an email address and fax number for the contact person).
Reassignment Terminations
Required Sections:
• Section 1 |
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• Section 3 |
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• Section 7 . . . |
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• Section 2 |
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• Section 4A |
(individual terming self) |
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Required Sections: |
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• Section 1 |
. . . |
• Section 3 |
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• Section 7 . . . |
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• Section 2 |
. . . |
• Section 4B |
(entity terming reassignment) . . . . . . . |
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Physicians and
Attachments Checklist
Have you submitted . . .
• Copy of the revalidation request letter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Copy of the medical license? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Copy of board certifications (NPPs only)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Copy of drivers license/current passport? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Copy of final adverse legal action documentation and resolution, if applicable? . . . . . .
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making change to existing banking information or if not currently enrolled as EFT? . . . . - Original voided check or bank letter? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
•Statement in writing from bank if Medicare payment is being sent to the same financial
institution that provider has a lending relationship? (See Supporting Documents -
Section 17 of
•IRS document preprinted with legal business name and EIN
(sole owner/proprietor only)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
• Copy of utility bill, if change to practice location (sole owner/proprietor only)? . . . . . .
• Business license, if applicable (sole owner/proprietor only)? . . . . . . . . . . . . . . . . . . . . . . .
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© 2012 Copyright, CGS Administrators, LLC.