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Last Modified: 12/6/2012
Location: FL, PR, USVI
Business: Part A, Part B
Provider/supplier enrollment applications
New enrollment, change of address, or update other enrollment information
New provider enrollment, address changes, and provider file updates (e.g., practice name or change of ownership) must be submitted on the proper Centers for Medicare & Medicaid Services (CMS) form 855, depending on the type of provider/supplier, or through Internet-based Provider Enrollment, Chain and Ownership System (PECOS). If you are submitting your information on paper, select the proper form below, based on provider/supplier type. If you are changing, adding, or deleting information, check the applicable box in each section, furnish the effective date and complete the appropriate fields in each section.
Internet-based PECOS
Find information about the Centers for Medicare & Medicaid Services’ online enrollment process, the Internet-based Provider Enrollment, Chain and Ownership System 
(PECOS). If you are familiar with Internet-based PECOS, click here to log in. Internet-based PECOS is the preferred method for submitting initial applications or making changes to your enrollment information.
(PECOS). If you are familiar with Internet-based PECOS, click here to log in. Internet-based PECOS is the preferred method for submitting initial applications or making changes to your enrollment information.Paper enrollment applications
Medicare provider/supplier enrollment applications (i.e., CMS-855) may be found at http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/index.html (Note: the provider enrollment Web page contains a link "CMS Forms List" but does not link directly to each individual form.).
(Note: the provider enrollment Web page contains a link "CMS Forms List" but does not link directly to each individual form.).The direct link for each Medicare provider/supplier enrollment application is shown below:
• CMS 855A for Institutional Providers: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855a.pdf 
• CMS 855B for Clinics/Group practices and Certain Other Suppliers: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf
• CMS 855I for Physicians and Non-Physician Practitioners: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf
• CMS 855R for Reassignment of Medicare Benefits: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855r.pdf
• CMS 855O for Eligible Ordering and Referring Physicians and Non-physician Practitioners http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855o.pdf
• CMS 855S for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855s.pdf
Mail completed paper provider/supplier enrollment applications to:
Provider Enrollment
P.O. Box 44021
Jacksonville, FL 32231-4021
P.O. Box 44021
Jacksonville, FL 32231-4021
