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 All CMS Forms link below.

1. CMS 855A--Medicare Enrollment Application for Institutional Providers
2. CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers
3. CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners
4. CMS 855R--Medicare Enrollment Application for Reassignment of Medicare Benefits
5. CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

SUBMITTING AN APPLICATION:

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)

Downloads
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Related Links Inside CMS
All CMS Forms DMEPOS Competitive Bid Medicare Provider-Supplier Enrollment Frequently Asked Questions
Related Links Outside CMS
There are no Related Links Outside CMS

Page Last Modified: 08/03/2010 2:47:39 PM
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