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Last Modified: 2/20/2018 Location: FL, PR, USVI Business: Part A, Part B

Provider enrollment application types

Q: How do I know which provider enrollment application to use?
A: You may either use the Provider Enrollment, Chain, and Ownership System (PECOS) external link to enroll online or mail a paper application form. PECOS supports the Medicare provider and supplier enrollment process by capturing provider/supplier information from the CMS-855 family of forms. The system manages, tracks, and validates enrollment data collected in both paper form and electronically via the internet. To find out more about PECOS, please refer to the PECOS FAQs external link.
The direct link for each Medicare provider/supplier enrollment application is shown below:
Institutional providers: CMS-855A external pdf file
Clinics/group practices and certain other suppliers: CMS-855B external pdf file
Physicians and non-physician practitioners (including clinical psychologists): CMS-855I external pdf file
Reassignment of benefits: CMS-855R external pdf file
Ordering, certifying and prescribing providers: CMS-855O external pdf file
Note: Ordering/referring providers must meet the criteria specified by SE 1305 external pdf file
Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers: CMS-855S 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.
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.
Not sure which CMS-855 form to complete? Learn more here.
Access the Provider Enrollment Application Assistance Tool for more help in determining the appropriate enrollment form for submission.
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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.