Information on Completing a CMS 855 Form

 

 

The CMS 855 form is used for applying for a Medicare PTAN number, changing information in an existing Medicare enrollment record and reassigning Medicare benefits.   Section 8 of this form is for “Billing Agency Information” The definition of a billing agency (billing service) is a company or individual that you contract with to prepare and submit your claims.  Please make sure you do not list Infinedi as your billing agency, this will delay the processing of your Medicare enrollment.

 

If you have any questions please contact customer service at 800-688-8087.  If you need a CMS855 form please contact your provider enrollment department of your local Medicare contractor.