Enrollment Applications
Did you know you can enroll online using PECOS? PECOS is the online Medicare enrollment management system which allows you to:
- Enroll as a Medicare provider or supplier
- Review information currently on file
- Upload your supporting documents
- Electronically sign and submit your information online
Because PECOS is paperless, you no longer need to submit anything by mail. Additionally, PECOS applications tend to process faster than paper applications.
Paper Enrollment Applications
The following forms can be used for initial enrollment, revalidations, changes in status, and voluntary termination:
- CMS-855A (PDF) for Institutional Providers
- CMS-855B (PDF) for Clinics, Group Practices, and Certain Other Suppliers
- CMS-855I (PDF) for Physicians and Non-Physician Practitioners
- CMS-855O (PDF) for Ordering and Certifying Physicians and Non-Physician Practitioners
- CMS-855S (PDF) for DMEPOS Suppliers
CMS is currently revising the 855S to reflect the new DMEPOS enrollment contractors and their mailing addresses.Effective Nov. 7, 2022, the National Supplier Clearinghouse no longer processes enrollment applications for DMEPOS suppliers. DMEPOS suppliers should send their 855S applications and related forms to their region's new enrollment contractor.Find your enrollment contractor (PDF).
- CMS-20134 (PDF) for MDPP Suppliers
The following forms are routinely submitted with an enrollment application:
- Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS-588 (PDF))
- Medicare Participating Physician or Supplier Agreement (Form CMS-460 (PDF))
Submit Your Application
When you’ve completed your paper application, print it and sign it. Your signature must be handwritten when you submit a paper application. Make a copy of the signed form for your records before mailing it to your enrollment contractor i with your supporting documents and EFT Authorization Agreement form.
i Medicare Administrative Contractors (MACs) process enrollment applications for health care providers and non-DMEPOS suppliers. The National Provider Enrollment DMEPOS East and West contractors process enrollment applications for DMEPOS suppliers.
Related Links
- CMS Forms List
- DMEPOS Competitive Bidding
