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Last Modified: 3/29/2024 Location: FL, PR, USVI Business: Part A, Part B

Provider enrollment decision tree

Individual, sole proprietor or disregarded entity, sole owner, group practice decision tree

To help determine if you should enroll as an individual in private practice, sole proprietor/disregarded entity, sole owner, or group practice/organization, please utilize the decision tree below.
Once you have determined how you should enroll, below is a list of what is needed for each individual/group type.
cision tree

Individual in private practice must have:

Medicare Enrollment Application – Physicians and Non-Physicians (CMS-855I external pdf file) for individual practitioner
SSN
Type 1 NPI (Individual NPI)
Medicare Enrollment Application - Electronic Funds Transfer Agreement (CMS-588 external pdf file) with a voided check or bank letterhead
If applicable:
Medicare Enrollment Application – Medicare Participating Physician or Supplier Agreement (CMS-460 external pdf file), if individual wants to have a participating status with Medicare

Sole proprietor/disregarded entity must have:

Physicians and Non-Physicians (CMS-855I external pdf file) for sole proprietor/disregarded entity
SSN
Type 1 NPI (Individual NPI)
Employer identification number
CP 575, IRS document
Electronic Funds Transfer Agreement (CMS-588 external pdf file) with a voided check or bank letterhead
If applicable:
Medicare Enrollment Application – Medicare Participating Physician or Supplier Agreement (CMS-460 external pdf file), if individual wants to have a participating status with Medicare
Additional Physicians and Non-Physicians (CMS-855I external pdf file) for any rendering providers

Sole owner must have:

Physicians and Non-Physicians (CMS-855I external pdf file) for sole owner
SSN
Type 1 NPI (Individual NPI)
Employer identification number
Type 2 NPI (Group NPI)
CP 575, IRS document
Electronic Funds Transfer Agreement (CMS-588 external pdf file) with a voided check or bank letterhead
If applicable:
Medicare Enrollment Application – Medicare Participating Physician or Supplier Agreement (CMS-460 external pdf file), if individual wants to have a participating status with Medicare
Additional Physicians and Non-Physicians (CMS-855I external pdf file) for any rendering providers

Group or organization must have:

Medicare Enrollment Application – Clinics/Group Practices and Other Suppliers (CMS-855B external pdf file)
Employer identification number
Type 2 NPI (Group NPI)
CP 575, IRS document
Electronic Funds Transfer Agreement (CMS-588 external pdf file) with a voided check or bank letterhead
If applicable:
Medicare Enrollment Application – Medicare Participating Physician or Supplier Agreement (CMS-460 external pdf file), if individual wants to have a participating status with Medicare
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.