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Get Medicare Form 855b 2022-2024

S have changes to: Sections A & B - Facility Name Sections A & C - Facility Shipping Address Sections A & D - Facility Shipping Hours Sections A & E - Signing Clinician Sections A & F - Prescribing Authorities Sections A & G - Patient Population Data Change Sections A & H - Primary and/or Back-up Vaccine Coordinator SECTION A: ORIGINAL FACILITY INFORMATION PIN: Today s Date: Original Facility Name: Vaccine Delivery Address: City: County: Zip Code: SECTION B: F.

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