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Home ► Provider enrollment applications and forms

Provider enrollment applications and forms

CMS-855 Provider/supplier enrollment applications

Modified: 3/30/2023

Determine which CMS-855 form fits your enrollment needs. Access all CMS-855 forms: 855A, 855B, 855I, 855O, 855R, and 855S.

Understanding which enrollment forms to complete

Modified: 9/11/2022

View basic form descriptions to assist you in determining which CMS-855 form to complete.

Internet-based PECOS external link

Modified: 10/7/2020

Find information about the Provider Enrollment, Chain and Ownership System (PECOS), the Centers for Medicare & Medicaid Services’ online enrollment process.

CMS-588 electronic funds transfer

Modified: 6/28/2022

Providers are required to sign up for electronic funds transfer (EFT) using a CMS-588 EFT form upon initial enrollment in the Medicare program or when changing enrollment information.

CMS-460 Medicare participating physician or supplier agreement pdf file

Modified: 11/8/2022

Participants agree to accept assignment for all covered services provided to Medicare patients. New physicians, practitioners, and suppliers may submit this form at the time of enrollment.

Medicare provider-supplier enrollment information external link

Modified: 10/7/2020

Medicare provider enrollment information for providers, physicians, non-physician practitioners, and other suppliers.

Medicare enrollment for ‘mass immunizers’

Modified: 5/31/2023

An entity or individual who wishes to furnish mass immunization services - but may not otherwise qualify as a Medicare provider - may be eligible to enroll as a “mass immunizer.”

Where to submit provider enrollment applications

Modified: 5/31/2023

Find information on where to submit enrollment applications and forms.

Enroll online -- Using Internet-based PECOS

Modified: 9/11/2022

Enrolling online saves you time, view these steps to get started.

CLIA laboratories referred billing attestation

Modified: 12/8/2020

Only one laboratory may bill for a referred laboratory service. It is the responsibility of the referring laboratory to ensure that the reference laboratory does not bill Medicare for the referred service when the referring laboratory does so or intends to do so.

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.