Provider Enrollment

Provider Enrollment Resources:

  • Enroll, change your Medicare information, and add or delete group members or locations online at Then print, sign and date the two-page Certification Statement and mail the Certification Statement and all supporting paper documentation to Palmetto GBA within seven days of electronic submission.
  • Download the CMS-855A form. Then print, sign and mail it to Palmetto GBA.
  • Access the status of your CMS-855 application
  • CMS file: providers eligible to order/refer and with current enrollment records
  • Enrollment Application Status Lookup
  • Palmetto GBA address for mailing enrollment forms:

    Palmetto GBA
    Part A Provider Enrollment (AG-331)
    2300 Springdale Drive, BLDG One
    Camden, SC 29020