Railroad Retirement Medicare Provider Enrollment Form

Legal Business Name

Provider Type / Specialty

Tax / Business Name (if different)

Primary Contact Name

First NameMiddle NameLast Name

Primary Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Primary Contact Email Address

example@example.com

Business Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Practice/Group Name

Primary Office Location

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Provider Enrollment Status

Effective Date Requested

Date

Service Area / Regions Served

Accepts Railroad Retirement Medicare Beneficiaries

Service categories provided

Claims submission method

Billing contact person

First NameMiddle NameLast Name

Billing contact email

example@example.com

Billing contact phone

Please enter a valid phone number.Format: (000) 000-0000.

Remittance address if different from business address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Business License or Certification

Tax Form (W-9 or Equivalent)

Malpractice or Coverage Proof

Provider Roster or Ownership Information