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Tools & forms: Enrollment

Tools

      Enrollment Gateway    

Enrollment / Revalidation Status

Application Assistance Tool

Forms

Download, view, fill, and print forms

Don't want to print and mail a paper enrollment form? You can enroll in Medicare by filling out these forms electronically using Internet Based-PECOS on the CMS website.

Forms, whether paper or electronic, must be completed by all providers of services and suppliers of medical and other health services for enrollment in the Medicare program.

The Medicare program uses the same forms (listed below) for new enrollment, revalidations, or changes to your existing enrollment information (practice name, address, etc.)

Note: Please make sure to obtain the latest paper enrollment form(s). In the event an enrollment form expires, you will be notified, and the newest version will be available on our website.

Part B (Physicians / Providers)

Form Description Instructions

CMS- 855B 

Clinics / Group Practices and Other Suppliers 

Clinics and group practices can apply for enrollment in the Medicare program or make a change to their existing enrollment information using the CMS-855B. 

Complete this application if you are an organization / group that plans to bill Medicare and you are:

  • A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, and portal x-ray suppliers).

    A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, and portal x-ray suppliers).

  • A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.

  • Currently enrolled with a Medicare fee-for-service (FFS) contractor but need to enroll in another FFS contractor’s jurisdiction.
  • Currently enrolled in Medicare and need to make changes to your existing enrollment data.
 CMS 855-B instructions

CMS- 855I 

Physicians and Non-Physician Practitioners 

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855I. 

Complete this application if you are an individual practitioner who plans to bill Medicare and you are:

  • An individual practitioner who will provide services in a private practice.
  • An individual practitioner who will provide services in a group setting.
  • Currently enrolled with a Medicare FFS contractor but need to enroll in another FSS contractor’s jurisdiction.
  • Currently enrolled in Medicare and need to make changes to your existing enrollment information.
  • An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you’re the sole owner.

Note: Sole owners will submit an 855B application for revalidation purposes, not an 855I application.

 CMS 855-I instructions

CMS- 855O

Ordering and Referring Physicians and Non-Physician Practitioners

Physician and non-physician practitioners can apply to register for the sole purpose of ordering and referring items and/or services to Medicare beneficiaries or make a change in their registration using the CMS-855O. These physicians and non-physician practitioners do not and will not send claims to a MAC for the services they furnish for reimbursement.

 CMS-855O instructions

CMS-20134 

Medicare Diabetes Prevention Program (MDPP) Suppliers

Complete and submit this application if you are an organization / group that plans to bill Medicare and you are:

  • An organization with CMS MDPP preliminary recognition or full Centers for Disease Control and Prevention (CDC) Diabetes Prevention Recognition Program (DPRP) Recognition.
  • Currently enrolled as an MDPP supplier with a Medicare FFS contractor but need to enroll in another FFS contractor's jurisdiction (e.g., you have opened an administrative location in a geographic territory serviced by another Medicare FFS contractor).
  • Currently enrolled in Medicare as an MDPP supplier and need to make changes to your enrollment data (e.g., you have added a community setting or coach)
 CMS-20134 instructions

CMS-588 

Electronic Funds Transfer Agreement

This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking.

 CMS-588 instructions

CMS-460 

Medicare Participation Agreement

Used to enroll or change your participating status with the Medicare Program.

 CMS-460 instructions

Clinical lab questionnaire

Clinical lab questionnaire form

Clinical labs are required to complete this questionnaire during the enrollment process which assists in determining if the referring laboratory may bill for tests performed by a reference laboratory.

 N/A

Part A (Facilities)

Form  Description Instructions

CMS-855A

Institutional Providers

Institutional providers can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855A. Complete this application if you are a health care organization and you plan to bill Medicare for Part A medical services or would like to report a change to your existing Part A enrollment data.

 CMS-855A instructions

CMS-588

Electronic Funds Transfer Agreement

This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking.

 CMS-588 instructions

Clinical lab questionnaire

Clinical lab questionnaire form

Clinical labs are required to complete this questionnaire during the enrollment process which assists in determining if the referring laboratory may bill for tests performed by a reference laboratory.

 N/A

Our Enrollment Gateway allows you the option to upload your paper enrollment application instead of mailing. For more information, please refer to our Enrollment Gateway User Guide.

Mailing information

If you cannot submit your information online through PECOS or the Enrollment Gateway, you may mail your completed paper application to First Coast, the MAC for jurisdiction N (JN) – Florida, Puerto Rico, and the U.S. Virgin Islands.

Provider Enrollment
P.O. Box 3409
Mechanicsburg, PA 17055-1849