Printable blank CMS-8550 Medicare Enrollment Application

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What is the blank CMS-8550 Medicare Enrollment Application?

The blank CMS-8550 Medicare Enrollment Application is a form used by the physicians and eligible professionals to enroll in the Medicare program.

What I need the blank CMS-8550 Medicare Enrollment Application for?

To enroll in the Medicare program as a physician or an eligible professional.

How to fill out the blank CMS-8550 Medicare Enrollment Application?

The fillable blank CMS-8550 Medicare Enrollment Application contains 10 pages. The form is pretty self-explanatory and contains detailed instructions both on how to fill it out and on which professionals are eligible to enroll in the Medicare program.

The first three pages of the printable blank CMS-8550 Medicare Enrollment Application are devoted to introductory information and brief instructions. The first section to be filled out is named “Basic Information”. It requires the applicant to select the reason for application and state the reason for enrolling solely to order and certify or prescribe part D drugs.
Section 2 is devoted to personal information and requires the applicant to enter their name, social security number, date of birth, Medicare identification number and more. This section also implies entering the educational and the license information.

Section 3 is named “Final Adverse Legal Actions” and it requires the applicant to list the final adverse legal action history. Section 4 covers the medical specialty information. It is filled out by selecting the physician specialty, eligible professional or other non-physician specialty type by checking the corresponding boxes.

Section 5 is to be filled out with the correspondence mailing address and the corresponding details. Section 6 is optional and gives an opportunity to select a contact person and bring up their details.
All the following sections are pre-filled and only require you to sign the form at the bottom of Page 9.

Organizations that work with the blank CMS-8550 Medicare Enrollment Application

The United States Department of Health & Human Services.

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