Enrollment Application: Form CMS-855 or CMS-20134

PECOS is the preferred method for provider enrollment. You’ll learn more about PECOS in the next few pages.

But first let’s discuss the paper application that the PECOS enrollment process is based on.

Enrolling as a Medicare provider involves completing Form CMS-855 or CMS-20134 for your provider type. The form and the information that it collects are the same whether you complete the paper form or use PECOS.

• Form CMS-855A: Institutional providers
• Form CMS-855B: Clinics, group practices, and certain other suppliers
• Form CMS-855I: Physicians and non-physician practitioners
• Form CMS-855O: For eligible ordering and certifying physicians and other eligible professionals
• Form CMS-855S: DMEPOS suppliers
• Form CMS-20134: Medicare Diabetes Prevention Program (MDPP) suppliers

If you don’t know which application to complete, contact the Medicare enrollment contractor who handles enrollment for your state or practice location. Find your MAC’s website.

Complete the paper form on your computer before printing, signing, and mailing it to your Medicare Administrative Contractor (MAC) or the National Provider Enrollment (NPE) DMEPOS East or West contractor. Make a copy of the signed form for your records, and don’t forget to add handwritten signatures in blue or black ink.

Remember: These instructions apply only to paper applications. The faster, easier, and preferred method for Medicare provider enrollment is PECOS.