This tool provides links to CMS-855 applications. These applications can be completed manually or electronically and then mailed or submitted online. Read this first before selecting from the list of options below:
To complete the appropriate CMS-855 application online, using Internet-based PECOS. Obtain an NPPES User ID and password to use Internet-based PECOS at https://nppes.cms.hhs.gov/NPPES/Welcome.do. Go to Internet-based PECOS at https://pecos.cms.hhs.gov, and then complete, review and submit the electronic enrollment application via Internet-based PECOS.
Important: Print, sign and date the two-page Certification Statement. Mail the Certification Statement and all supporting paper documentation to the Medicare contractor within seven days of electronic submission. This is a requirement.
Note: The effective date of filing an enrollment application is the date Palmetto GBA receives the signed Certification Statement that is associated with the Internet submission.
Enrolling as an individual, please select your specialty:
Enrolling as a Member of a Group, please select your specialty:
Enrolling as a Group, please select the following:
Enrolling as an Organization, please select your facility's specialty:
Reporting changes in your practice, please complete the identified sections in the chart: