Form CMS-855A – Medicare Enrollment Application for

10.3.1.1 – Form CMS-855A – Medicare Enrollment Application for Institutional Providers (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) Institutional providers (e.g., hospitals) that will furnish Medicare Part A services to beneficiaries must complete the Form CMS-855A. For purposes of this section 10.3.1.1 et seq. (and except as otherwise stated), the term “provider” includes certified suppliers that must complete the Form CMS-855B.