Enrollment Applications

Enrollment Applications
Did you know you can enroll online using PECOS?

PECOS is the online Medicare enrollment management system which allows you to:

  • Enroll as a Medicare provider or supplier
  • Review information currently on file
  • Upload your supporting documents
  • Electronically sign and submit your information online

Because PECOS is paperless, you no longer need to submit anything by mail. Additionally, PECOS applications tend to process faster than paper applications.

Enroll online using PECOS.

Paper Enrollment Applications

The following forms can be used for initial enrollment, revalidations, changes in status, and voluntary termination:

  • CMS-855A for Institutional Providers
  • CMS-855B for Clinics, Group Practices, and Certain Other Suppliers
  • CMS-855I for Physicians and Non-Physician Practitioners
  • CMS-855R for Reassignment of Medicare Benefits
  • CMS-855O for Ordering and Certifying Physicians and Non-Physician Practitioners
  • CMS-855S for DMEPOS Suppliers
  • CMS-20134 (PDF) for MDPP Suppliers

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)
Submit Your Application

When you’ve completed your paper application, print it and sign it. Your signature is required to be handwritten when you submit a paper application. Make a copy of the signed form for your records before mailing it to your Medicare Administrative Contractor (MAC)i with your supporting documents and EFT Authorization Agreement form.

Find your MAC (PDF).

 

i DMEPOS suppliers would submit their paper enrollment applications to the National Supplier Clearinghouse.

Page Last Modified:
09/21/2020 12:50 PM