New Client Entity Information Form – Complete this form if you are a new client with nCred who has signed a service agreement. This form provides us detailed information about your business entity.
New Client Provider Information Form – Complete this form if you are a new client with nCred or are an existing nCred client who is adding a new provider to your practice. This information form provides us with the necessary details of your new provider so that we may process your health plan enrollment applications.
Primary Source Verification Application – Complete this form if you are a healthcare provider who is applying for facility privileges at a facility for whom nCred handles all provider credentials verification. This form must be filled out and e-signed by the provider in order to begin your credentialing process with the facility.
What is a CP575? The CP575 is the confirmation letter that you get from the IRS when you obtain a Employer Identification Number – EIN or “Tax Id#” for a business. To enroll with Medicare, you must provide a copy of this letter as proof of the legal name of the business. If you do not have the original CP575, then you can request a replacement letter 147C to verify your EIN. These two documents are the only documents that Medicare accepts as proof of your EIN.
Click here for an example of a CP575 To request a replacement letter 147C, you can call the IRS business center at (800) 829-4933. The hours of operation are 7:00 a.m. – 7:00 p.m. local time, Monday through Friday. Allow 4-6 weeks for processing the request.
W-9, Taxpayer Identification Verification Form
Medicare Provider Enrollment Forms and Information
Medicare Enrollment Forms
CMS 855A Medicare Enrollment Application – Institutional Providers
CMS 855B Medicare Enrollment Application – Clinics/Group Practices and Certain Other Suppliers
CMS 855I Medicare Enrollment Application – Physicians and Non-Physician Practitioners
CMS 855O Medicare Enrollment Application – For Eligible Ordering and Referring Physicians and Non-Physicians
CMS 855R Medicare Enrollment Application – Reassignment of Medicare Benefits
CMS 855SMedicare Enrollment Application – Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS)
CMS 588 Electronic Funds Transfer (EFT) Authorization Agreement
CMS 460 Medicare participating physician or supplier agreement