Palmetto GBA: , Medical Nutrition Therapist RD/LD: Group Member

You may change your answers at any time, or simply start over.

A. Does the enrollee have/had a Medicare Provider Transaction Access Number (PTAN) within Palmetto GBA's jurisdiction? Yes No

B. Is the group the enrollee is reassigning benefits to enrolled with an active Medicare PTAN/Legacy number within Palmetto GBA's jurisdiction? Yes No

Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov

Complete form 855R sections 1-4, and 7

CMS 855R form (CMS Web site)

Section 4a (Reassignment of Benefits Statement) of the 855R must be signed and dated by the enrollee that is reassigning benefits. Faxed, photocopied, or stamped signatures are not accepted.

Section 4b (Attestation Statement) of the 855R must be signed and dated by the person that is an 'authorized' or 'delegated' official for the group. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

State RD/LD License

Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

JM Mailing Address JJ Mailing Address

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Be sure to:

Complete all required information, including any boxes to indicate “not applicable.”

Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”

Provide information required for Electronic Fund Transfer.

Sign your application in BLUE ink.

Date your application.

Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.

Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.

Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

C. Does the enrollee want to participate in the Medicare Program accepting assignment on all Medicare Part B claims? (Medicare providers have the choice to be classified as participating or non-participating.) Yes No

D. Does the group have at least one member that will receive a Medicare Part B Provider Transaction Access Number (PTAN)? Yes No

Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov

Complete form 855R sections 1-4 and 7

CMS 855R form (CMS Web site)

Section 4a (Reassignment of Benefits Statement) of the 855R must be signed and dated by the enrollee that is reassigning benefits. Faxed, photocopied, or stamped signatures will not be accepted.

Section 4b (Attestation Statement) of the 855R must be signed and dated by the person that is an 'authorized' or 'delegated' official for the group. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

State RD/LD License

The enrollee's group needs to be enrolled using the CMS 855B form.
Note: New groups enrolling in the Medicare Part B program must have at least one group member. The forms must be submitted together.

Complete form 855B sections 1-6, 8, 13, 15, 16 (optional), and 17

CMS 855B form (CMS Web site)

Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

Participating Agreement: CMS 460 form (CMS Web site)

IRS documentation (e.g., CP575, quarterly tax coupon confirming the tax identification number and legal business name of the enrollee.

State Business License

Electronic Funds Transfer (EFT)

EFT CMS 588 form (CMS Web site)

A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.

Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

JM Mailing Address JJ Mailing Address

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Be sure to:

Complete all required information, including any boxes to indicate “not applicable.”

Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”

Provide information required for Electronic Fund Transfer.

Sign your application in BLUE ink.

Date your application.

Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.

Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.

Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

D. Does the group have at least one member that will receive a Medicare Part B Provider Transaction Access Number (PTAN)? Yes No

Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov

Complete form 855R sections 1-4 and 7

CMS 855R form (CMS Web site)

Section 4a (Reassignment of Benefits Statement) of the 855R must be signed and dated by the enrollee that is reassigning benefits. Faxed, photocopied, or stamped signatures will not be accepted.

Section 4b (Attestation Statement) of the 855R must be signed and dated by the person that is an 'authorized' or 'delegated' official for the group. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

State RD/LD License

The enrollee's group needs to be enrolled using the CMS 855B form.
Note: New groups enrolling in the Medicare Part B program must have at least one group member. The forms must be submitted together.

Complete form 855B sections 1-6, 8, 13, 15, 16 (optional), and 17

CMS 855B form (CMS Web site)

Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

IRS documentation (e.g., CP575, quarterly tax coupon confirming the tax identification number and legal business name of the enrollee.

State Business License

Electronic Funds Transfer (EFT)

EFT CMS 588 form (CMS Web site)

A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.

Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

JM Mailing Address JJ Mailing Address

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Be sure to:

Complete all required information, including any boxes to indicate “not applicable.”

Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”

Provide information required for Electronic Fund Transfer.

Sign your application in BLUE ink.

Date your application.

Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.

Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.

Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

B. Is the group the enrollee is reassigning benefits to enrolled with an active Medicare PTAN/Legacy number within Palmetto GBA's jurisdiction? Yes No

Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov

Complete form 855I (sections 1, 2, 3, 4b, 13, 15, and 17)

CMS 855I form (CMS Web site)

Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Complete form 855R sections 1-4 and 7

CMS 855R form (CMS Web site)

Section 4a (Reassignment of Benefits Statement) of the 855R must be signed and dated by the enrollee that is reassigning benefits. Faxed, photocopied, or stamped signatures will not be accepted.

Section 4b (Attestation Statement) of the 855R must be signed and dated by the person that is an 'authorized' or 'delegated' official for the group. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

State RD/LD License

Electronic Funds Transfer (EFT)

Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

JM Mailing Address JJ Mailing Address

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Be sure to:

Complete all required information, including any boxes to indicate “not applicable.”

Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”

Provide information required for Electronic Fund Transfer.

Sign your application in BLUE ink.

Date your application.

Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.

Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.

Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

C. Does the enrollee want to participate in the Medicare Program accepting assignment on all Medicare Part B claims? (Medicare providers have the choice to be classified as participating or non-participating.) Yes No

D. Does the group have at least one member that will receive a Medicare Part B Provider Transaction Access Number (PTAN)? Yes No

Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov

Complete form 855I sections 1, 2, 3, 4b, 13, 15, and 17

CMS 855I form (CMS Web site)

Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Complete form 855R sections 1-4 and 7

CMS 855R form (CMS Web site)

Section 4a (Reassignment of Benefits Statement) of the 855R must be signed and dated by the enrollee that is reassigning benefits. Faxed, photocopied, or stamped signatures will not be accepted.

Section 4b (Attestation Statement) of the 855R must be signed and dated by the person that is an 'authorized' or 'delegated' official for the group. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

State RD/LD License

The enrollee's group needs to be enrolled using the CMS 855B form.
Note: New groups enrolling in the Medicare Part B program must have at least one group member. The forms must be submitted together.

Complete form 855B sections 1-6, 8, 13, 15, 16 (optional), and 17

CMS 855B form (CMS Web site)

Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

Participating Agreement: CMS 460 form (CMS Web site)

IRS documentation (e.g., CP575, quarterly tax coupon confirming the tax identification number and legal business name of the enrollee.

State Business License

Electronic Funds Transfer (EFT)

EFT CMS 588 form (CMS Web site)

A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.

Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

JM Mailing Address JJ Mailing Address

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Be sure to:

Complete all required information, including any boxes to indicate “not applicable.”

Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”

Provide information required for Electronic Fund Transfer.

Sign your application in BLUE ink.

Date your application.

Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.

Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.

Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

D. Does the group have at least one member that will receive a Medicare Part B Provider Transaction Access Number (PTAN)? Yes No

Note: CMS now requires all providers enrolling or making an update to their file to include the NPI on the CMS 855 forms. Submit a copy of the NPI notification letter from the NPI Enumerator (NPI) https://nppes.cms.hhs.gov

Complete form 855I sections 1, 2, 3, 4b, 13, 15, and 17

CMS 855I form (CMS Web site)

Section 15 (Certification Statement) of the 855I must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Complete form 855R sections 1-4 and 7

CMS 855R form (CMS Web site)

Section 4a (Reassignment of Benefits Statement) of the 855R must be signed and dated by the enrollee that is reassigning benefits. Faxed, photocopied, or stamped signatures will not be accepted.

Section 4b (Attestation Statement) of the 855R must be signed and dated by the person that is an 'authorized' or 'delegated' official for the group. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

State RD/LD License

The enrollee's group needs to be enrolled using the CMS 855B form.
Note: New groups enrolling in the Medicare Part B program must have at least one group member. The forms must be submitted together.

Complete form 855B sections 1-6, 8, 13, 15, 16 (optional), and 17

CMS 855B form (CMS Web site)

Section 15 (Certification Statement) of the 855B must be signed and dated by the enrollee. Faxed, photocopied, or stamped signatures will not be accepted.

Include the following documents:

IRS documentation (e.g., CP575, quarterly tax coupon confirming the tax identification number and legal business name of the enrollee.

State Business License

Electronic Funds Transfer (EFT)

EFT CMS 588 form (CMS Web site)

A copy of a voided pre-printed check, a pre-printed deposit ticket, or a bank verification letter.

Completed forms and supporting documentation should be mailed to Provider Enrollment at the address below:

JM Mailing Address JJ Mailing Address

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Palmetto GBA
Part B Provider Enrollment
Mail Code: AG-310
P.O. Box 100306
Columbia, SC 29202-3306

Overnight, UPS, Fed Ex, etc correspondence can be mailed to:
Palmetto GBA
2300 Springdale Drive
Building One
Camden, SC 29020-1728

Be sure to:

Complete all required information, including any boxes to indicate “not applicable.”

Include effective date in all appropriate sections, for example, section 4b, “Practice Information.”

Provide information required for Electronic Fund Transfer.

Sign your application in BLUE ink.

Date your application.

Submit copies of all appropriate licenses, agreements and tax documents.

Important Information:

Providers must submit ALL required application combinations at the same time; not doing so results in the physical return of the provider's mailed request.

Required documentation must be submitted with the initial application(s); not doing so results in delayed processing.

Signature errors are the number 1 reason application processing is delayed. Ensure the right Delegated Official, Authorized Official and Applicant signs and dates the appropriate section(s) prior to submission.

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

JM Mailing Address	JJ Mailing Address
Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100190 Columbia, SC 29202-3190 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728	Palmetto GBA Part B Provider Enrollment Mail Code: AG-310 P.O. Box 100306 Columbia, SC 29202-3306 Overnight, UPS, Fed Ex, etc correspondence can be mailed to: Palmetto GBA 2300 Springdale Drive Building One Camden, SC 29020-1728

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