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Last Modified: 11/6/2014 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 external link (PECOS). If you are familiar with Internet-based PECOS, click here external link 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 external link (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 855B for Clinics/Group practices and Certain Other Suppliers: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf external pdf file
CMS 855I for Physicians and Non-Physician Practitioners: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf external pdf file
CMS 855R for Reassignment of Medicare Benefits: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855r.pdf external pdf file
CMS 855O for Eligible Ordering and Referring Physicians and Non-physician Practitioners http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855o.pdf external pdf file
CMS 855S for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers: http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855s.pdf external pdf file. Note: CGS Medicare external link is the DMEPOS Medicare Administrative Contractor (MAC) for Florida, Puerto Rico, and the U.S. Virgin Islands.
Not sure which CMS-855 form to complete? Learn more here.
Mail completed paper provider/supplier enrollment applications to:
Provider Enrollment
P.O. Box 44021
Jacksonville, FL 32231-4021

Additional information

Additional information concerning enrollment applications may be found in Part A or Part B provider enrollment FAQs.

First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.