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For initial enrollment and revalidation, the certification statement must be signed and dated (preferably in blue ink) by an authorized official. List the city/town, county, state/territory, or zip code for all locations where you render health care services in patients’ homes or, if previously reported, where you no longer render health care services in patients’ homes. I understand that the medicare identification number (ptan) issued to me can only be used by me or by a medicare enrolled provider or supplier to whom i have reassigned my benefits under current medicare regulations when billing for services rendered by me.

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Make a copy of the signed form for your records before mailing it to your enrollment contractor with your supporting documents and eft authorization agreement form. Faxed, photocopied, or stamped signatures will not be accepted. Section 15 (certification statement) of the 855b must be signed and dated by the person being recognized as the authorized official