The full name of the individual submitting this information form.
This is the physical address of your practice
Managing Employee or Authorized Official:
It is recommended that your managing employee or authorized official is the doctor/dentist making this application.
Bank Information for Electronic Funds Transfer
Medicare requires EFT to be enrolled.
You must provide the contact information for your personal banker or branch manager of the branch where you bank.
Address to local bank branch
Please provide the personal and professional information for the doctor/dentist
NOTE: This may be an estimated date.
Your business mailing address must be a physical address and not a post office box.
Who handled the legal processing of the adverse legal action.
Upload Required Documents
You must upload the required documentation below when submitting this completed request. Valid and current copies are required. The current dates on these are important.
Select the Medicare application services you want for this location and provider. Note: DME (Durable Medical Equipment such as sleep appliances) Part B covers procedures such as oral surgery, diagnostics and radiology.
NOTE: YOU MAY ONLY SELECT ONE DME AND ONE PART B APPLICATION.
I understand that I will NOT be able to balance bill if I select DME Participating
NOTE: Application Fees are a one-time charge.