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

1. Complete form 855I (sections 1, 2, 3, 4, 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.
   • The provider will receive 2 provider numbers using the 855I Form (one for the corporation and one for the individual.)
   • Incorporated providers need to get an NPI for their corporation as well as for themselves. https://www.nppes.cms.hhs.gov
2. Include the following documents:
   • State Audiologist license
   • 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.
3. 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.
4. Submitting Claims Electronically - Electronic Data Interchange (EDI)
   • There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
   • New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin.
5. 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.

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

1. Complete form 855I (sections 1-6, 8, 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.
2. Include the following documents:
   • State Audiologist license
   • 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.
3. 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.
4. Submitting Claims Electronically - Electronic Data Interchange (EDI)
   • There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
   • New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin.
5. 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.

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

1. 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.
   • The provider will receive 2 provider numbers using the 855I Form (one for the corporation and one for the individual.)
   • Incorporated providers need to get an NPI for their corporation as well as for themselves. https://www.nppes.cms.hhs.gov
2. Include the following documents:
   • State Audiologist license
   • IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee.
3. 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.
4. Submitting Claims Electronically - Electronic Data Interchange (EDI)
   • There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
   • New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin.
5. 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.

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

1. Complete form 855I (sections 1-6, 8, 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.
2. Include the following documents:
   • State Audiologist license
   • IRS documentation (e.g., CP575, quarterly tax coupon) confirming the tax identification number and legal business name of the enrollee.
3. 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.
4. Submitting Claims Electronically - Electronic Data Interchange (EDI)
   • There are many advantages to submitting claims electronically. In most cases, submitting electronically is required due to ASCA (Administrative Simplification Compliance Act).
   • New Providers, as well as existing providers who are assigned a new PTAN (Provider Transaction Access Number), must enroll for EDI using an EDI Enrollment Form. To access the Enrollment Forms go to: http://www.PalmettoGBA.com/jmb/edi, select Enrollment from left margin.
5. 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.