Last Modified: 7/9/2021
Location: FL, PR, USVI
Business: Part A, Part B
The enrollment application assistance tool
removes the guesswork for providers trying to figure out which enrollment form to use, whether they are submitting an initial enrollment, a change of information, revalidation or even terminating their Medicare enrollment.
This tool offers tips to clarify
what should be included in each relevant section of the appropriate enrollment form as well as what additional documentation is needed to complete the process.
New provider enrollment, address changes, and provider file updates (e.g., practice name or change of ownership) must be submitted on the proper 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.
For assistance with changing information online through internet-based PECOS, view the following tutorials hosted by CMS:
The direct link for each Medicare provider/supplier enrollment application is shown below:
Mail completed paper provider/supplier enrollment applications to:
P.O. Box 3409
Mechanicsburg, PA 17055-1849
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.