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Not all items will be applicable for all provider types.  \nGather the required information  \nEnrollment Application/Internet-Based PECOS Access  \nIRS paperwork for businesses or social security information for an individual  \nCopies of certification, licenses, or accreditations  \nNational Provider Identifier (NPI)  \nCorrespondence address  \nPhysical location addresses  \n􀁸 Practice location address  \n􀁸 Medical record address  \n􀁸 Payment address  \n􀁸 City, state, ZIP code Organizational Owners  \n􀁸 Tax Identification Number  \n􀁸 Legal business name  \n􀁸 Doing Business As Name (if applicable)  \n􀁸 Address and phone number  \n􀁸 NPI  \n􀁸 Medicare Identification Number (if already existing provider)  \n􀁸 Effective date of ownership  \n􀁸 Effective date of managing control  \n􀁸 Organizational structure Individual Owners  \n􀁸 Social Security Number  \n􀁸 Address and phone number  \n􀁸 NPI  \n􀁸 Medicare Identification Number (if already existing provider)  \n􀁸 Effective date of ownership  \n􀁸 Effective date of managing control  \nGather the situational information  \nElectronic Funds Transfer (EFT) agreement  \n􀁸 New enrollees or if changes are needed  \n􀁸 Voided check or bank letter  \n11/07/2018  [https://www.wpsgha.com](https://www.wpsgha.com) Page 1 of 3  \nFinal documents for adverse legal action  \n􀁸 Organizational  \n􀁸 Individual provider  \n􀁸 Managing or controlling organization  \n􀁸 Managing or controlling individual Vehicle information  \n􀁸 Vehicle identification number  \n􀁸 Type of vehicle Billing agency information  \n􀁸 Legal name  \n􀁸 Doing business as name  \n􀁸 Address and phone number Acquiring provider  \n􀁸 501 C 3 IRS tax exempt letter (Non-profit only)  \n􀁸 Diagram of entity in Sections 5 Ownership Interest And/or Managing Control Information (Organizations) of 855A  \nGather the provider specific information  \nIf a provider or specialty type is not listed below, no additional documentation is required.  \nAmbulance  \n􀁸 Vehicle identification Number  \n􀁸 EMT license numbers  \n􀁸 Base operation address  \n􀁸 Geographic information of area served Children’s Hospital Only  \n􀁸 Receive demographics for past six months showing age of patient population in order to verify that 50% of hospital's inpatients are under age of 18  \n􀁸 42 CFR 412.23(d): Servicing intermediary verifies compliance that more than 50% of its inpatients are individuals under age of 18  \nCommunity Mental Health Center (CMHC) instructions  \n􀁸 Exhibit 275 Compliance Attestation Statement Form  \n􀁸 Exhibit 282 Attachment 8 CMHC site visit request form  \n􀁸 Written letter describing services provided and the full-time employees or equivalent  \n􀁸 Documentation showing 40% of clients receiving services are NOT Medicare Comprehensive Outpatient Rehabilitation Facility (CORF)  \n􀁸 Diagram of entity in Sections 5 Ownership Interest And/or Managing Control Information (Organizations)  \n􀁸 Attestation letter, if a government entity  \n11/07/2018  [https://www.wpsgha.com](https://www.wpsgha.com) Page 2 of 3  \nDoctor/Non-Physician Practitioner  \n􀁸 Resident/fellow information  \n􀁸 Specialty information  \n􀁸 Physician Assistant employment agreement  \n􀁸 Participation agreement (CMS Form 460) Facilities part of a chain  \n􀁸 Home office administrator information  \n􀁸 Name  \n􀁸 Title  \n􀁸 Social security number  \n􀁸 Date of birth  \n􀁸 Home office  \n􀁸 Name and address  \n􀁸 Tax identification  \n􀁸 Chain number  \n􀁸 Cost report year-end date  \n􀁸 Structure  \nFederally Qualified Health Centers (FQHC)  \n􀁸 Health Resources and Services Administration (HRSA) Grant Award with site address listed  \n􀁸 Address not listed, include HRSA and a copy of Form 5 Part B Services Site form with address  \n􀁸 If no HRSA, FQHC \"Look-A-Like\" letter from CMS  \n􀁸 Exhibit 177 (Compliance/Funding form) Independent Diagnostic Testing Facility (IDTF)  \n􀁸 Procedure code performed  \n􀁸 Equipment  \n􀁸 Model Number  \n􀁸 Interpreting physician information  \n􀁸 Su","cbCaifrkETVz6onM","https://ap.wps.com/l/cbCaifrkETVz6onM","pdf",129558,"English","# Medicare Enrollment Checklist\n## Gather the required information\n## Gather the situational information\n## Final documents for adverse legal action\n## Gather the provider specific information","[{\"question\":\"这份清单适用于所有Medicare提供方类型吗？\",\"answer\":\"不一定。表单说明并非所有条目都适用于所有提供方类型，需按具体类型选择相关材料。\"},{\"question\":\"完成注册申请通常需要哪些基础信息？\",\"answer\":\"需要准备注册申请/互联网式PECOS访问所需信息，包括IRS文件或个人社保信息、认证/执照/资质复印件、NPI、通信地址与机构或个人的相关身份与控制管理生效日期等。\"},{\"question\":\"哪些情境信息需要额外提供？\",\"answer\":\"包括EFT（电子资金转账）协议，并根据要求提供新注册人或变更所需材料，如作废支票或银行证明。\"}]","Medicare Enrollment Checklist - complete the enrollment process | PDF",1790155633]