You submitted the 11/2001 version of the CMS-855 application. The application has been revised, and the Centers for Medicare & Medicaid Services (CMS) requires version 04/06 or 06/06.

The correct version of the applications may be downloaded at: www.cms.hhs.gov/Medicare
ProviderSupEnroll/

The CMS-855I application was signed by someone other than the individual practitioner applying for enrollment.

The application must be signed by the individual practitioner applying for enrollment.

The wrong application was completed.

The following applications are available on CMS’ Web site:

CMS 855A--Medicare Enrollment Application for Institutional Providers

CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers

CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners

CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits

CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier

You failed to submit all of the forms needed to process a reassignment package within 15 calendar days of receipt.

It is imperative to return all requests for additional information immediately back to the carrier.

The application was not signed and/or dated.

Please remember to sign and date the application in the necessary fields.

The application contained a copied or stamped signature.

Original signatures are required.

You submitted the application to the wrong contractor.

Applications for providers practicing in NY:

Provider Enrollment
National Government Services, Inc.
P.O. Box 1200
Crompond, NY 10517-1200

Applications for providers practicing in NJ :

NJ Provider Enrollment Services
P.O. Box 69218
Harrisburg , PA 17106-9218

You completed the application in pencil.

Applications must be completed in ink.

The Web-generated application you submitted does not appear to have been downloaded from the CMS Web site.

Applications must be downloaded from:

www.cms.hhs.gov/Medicare
ProviderSupEnroll/

The contractor received the application more than 30 days prior to the effective date listed on the application.

Applications can not be received any earlier than 30 days prior to the practice effective date listed on the application.

The application was not mailed (i.e., it was faxed or e-mailed.)

All applications must be sent via the mail.