Notes

Medicare Provider/Supplier Enrollment Applications

The Medicare enrollment application (CMS-855 or Internet-based Provider Enrollment, Chain and Ownership System (PECOS)) is an Office of Management and Budget approved form and is available in PDF fillable format. This format allows a user to complete an application using Adobe Acrobat and save this information on their personal computer or download the application. To access the applications, please refer to the CMS Forms List link below.

CMS-855A Medicare Enrollment Application for Institutional Providers
CMS-855B Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers
CMS-855I Medicare Enrollment Application for Physicians and Non-Physician Practitioners
CMS-855R Medicare Enrollment Application for Reassignment of Medicare Benefits
CMS-855O Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners
CMS-855S Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
CMS-855POH Medicare Enrollment Application for Physician Owned Hospitals
CMS-20134 Medicare Enrollment Application for Medicare Diabetes Prevention Program (MDPP) Suppliers
SUBMITTING AN APPLICATION:

Medicare enrollment application forms are fillable on your computer. This means that you can fill out the information required by typing into the open fields while the form is displayed on your computer monitor. Filling out the forms this way before printing, signing and mailing means more easily-readable information – which means fewer mistakes, questions, and delays when your application is processed. Be sure to make a copy of the signed form for your records before mailing.

Signatures are still required to be handwritten. Don't forget to complete this important step prior to mailing your typed form(s).

Keep in mind that typed forms are easier for Medicare to process, but the most efficient method for submitting your enrollment application is to use the Internet –Based Provider Enrollment, Chain and Ownership System (PECOS). PECOS guides you through the enrollment application so you only supply information relevant to your application. PECOS also reduces the need for follow-up because of incomplete applications. Using Internet-based PECOS results in a more accurate application and saves you time and administrative costs. Click on the Internet- Based PECOS tab on the left to learn more.

Mail your completed application and all supporting documentation to the Medicare fee-for-service contractor (also referred to as a carrier, fiscal intermediary, Medicare Administrative Contractor, or the National Supplier Clearinghouse) serving your State or geographic location. To find the Medicare fee-for-service contractor serving your State or geographic location, please return to the "Overview" section of this web site and select the first download titled, "Medicare Fee-For-Service Contact Information." To avoid delays in application processing, do not mail your application to the Centers for Medicare & Medicaid Services in Baltimore, Maryland.

Note: If you are enrolled in Medicare, but have not submitted a CMS-855 since 2003, you are required to submit a complete application. Providers and suppliers should follow the instructions for completing an initial enrollment application.

By submitting a Medicare enrollment application, a physician provider or other supplier will establish an enrollment record in PECOS. For physicians and eligible non-physician practitioners, this means that your name and National Provider Identifier will be added to the Ordering and Referring Report during the next update cycle.

ACCREDITATION:

For information regarding Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier accreditation and the DMEPOS accreditation organizations, please select the link titled, "Competitive Acquisition for DMEPOS" from the section titled, "Links Inside CMS" below.

ADDITIONAL FORMS:

The following forms are routinely submitted with an enrollment application:

Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS-588)
Medicare Participating Physician or Supplier Agreement (Form CMS-460)
Rel