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CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

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Supporting Documents

Attach required supporting documentation for individuals or organizations.

Submit applicable documents.

  • CMS-588 EFT Authorization Agreement and voided check or bank confirmation letter
  • IRS document confirming your legal business name and EIN (e.g., IRS, CP-575 or CP-147C)
  • Medical license/certification
  • National Certification for nonphysician practitioners
  • Business license
  • Final adverse legal action documentation
  • Accreditation
  • CMS-460 Medicare Participating Physician or Supplier Agreement  
  • Application fee receipt or hardship exception request
  • Documentation verifying IDTF supervisory physician(s) proficiency and/or state licenses or certifications for IDTF nonphysician personnel
  • Comprehensive liability insurance policy (IDTFs only)
  • Documentation verifying state licenses or certifications of the laboratory director or nonphysician practitioner personnel of an independent clinical laboratory
  • FAA 135 certification (air ambulance suppliers)
  • Ambulance vehicle registration
  • Attestation for government entities and tribal organizations
  • IRS Form 8832 confirmation of disregarded entity
  • Lending relationship ‒ Statement in writing from the bank detailing agreement to waive its rights of offset for Medicare receivables

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