Specialty Code 01, 08 & 11
Attention: All General Practice, Family Practice and Internal Medicine Providers
Billing groups should complete the form CMS 855I for Individual Health Care Practitioners either on-line through the internet-based Provider Enrollment Chain and Ownership System (PECOS) or the paper enrollment application process. The following sections should be completed:
• Section 1A PTAN/NPI and check off Change
• Section 2A 2D Identifying Info, Specialty, etc.
• Section 3 Adverse Action
• Section 13 Contact Person
• Section 15 Signature
Upon receipt of your application, you may be required to provide additional information in order to process your request.
Internet-based PECOS:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
published 09/2012