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Last Modified: 6/19/2018 Location: FL, PR, USVI Business: Part A, Part B

How to complete a CMS-855 form

Q: How do I complete a CMS-855 form? How can I be sure that I have everything I need?
A: Medicare enrollment applications/forms (CMS-855A, CMS-855B, CMS-855I, and CMS-855R) must be completed with accurate information and include all supporting documentation.
First Coast Service Options Inc. (First Coast) offers several online resources to assist you during the provider enrollment process including:
CMS-855 tutorials
Institutional providers: CMS-855A flash file
Clinics/group practices and certain other suppliers: CMS-855B flash file
Physicians and non-physician practitioners: CMS-855I flash file
Reassignment of benefits: CMS-855R flash file
Provider enrollment tips, terms, and specialty codes:
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form and documentation for submission.
Note: The Centers for Medicare & Medicaid Services approved two new enrollment forms, CMS-855C and CMS-855POH. For more information, access the change request (CR) 9120 external pdf file and the CMS Forms List external link page.
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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.