Form CMS-855I – Medicare Enrollment Application for Physicians

10.3.1.3 – Form CMS-855I – Medicare Enrollment Application for Physicians and Non-Physician Practitioners (Rev. 12639; Issued: 05-16-24; Effective: 06-17-24; Implementation: 06-17-24) This application should be completed by physicians and non-physician practitioners who render Medicare Part B services to beneficiaries and, as applicable, wish to reassign their benefits under § 424.80. (This includes a physician or practitioner who (1) is the sole owner of a professional corporation, professional association, or limited liability company and (2) will bill Medicare through this business entity.)