- Form #
- CMS 855O
- Form Title
- Medicare Enrollment Application - For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
- Revision Date
- 08/01/2012
- O.M.B. #
- 0938-1135
- O.M.B. Expiration Date
- 08/31/2015
- CMS Manual
- N/A
- Special Instructions
- N/A
