How to Enroll

How to Submit a Provider Enrollment Application:

Step 1:
Download the CMS Form 855A from the CMS website at http://www.cms.hhs.gov/CMSForms/downloads/CMS855A.pdf

Step 2:
Determine the reason for submitting the application and complete all required sections of the application.

Step 3:
Complete all required fields on the application and gather required supporting documentation.

Step 4:
All enrollment applications and supporting documentation must be submitted via regular mail to:

Riverbend Government Benefits Administrator
Provider Enrollment Department
730 Chestnut Street
Chattanooga, TN 37402

Special mail handling can delay the delivery and processing of your applications.

Riverbend