Participation Agreement Form and Instructions

How To Complete a Medicare Participating Physician or Supplier Agreement (CMS-460)
Upon receipt of a new Medicare provider number, a new Medicare provider entity has 90 days to submit to the Medicare carrier or A/B MAC a signed Medicare Participating Physician or Supplier Agreement (CMS-460). A participating provider enters into an agreement to accept the Medicare-approved amount as full payment for services and supplies covered under Part B. This agreement (CMS-460) renews automatically each year. Exception: A change in name and/or EIN (tax identification number) is a change in identity and requires a new participation decision. A participating provider receives five percent more on reimbursement for physician related services. Those who have not signed a participation agreement are listed as non-participating providers and are subject to the limiting charge fee schedule. The Medicare Participating Physician or Supplier Agreement (CMS-460) is available by clicking on the link below. Complete and mail the signed form to Palmetto GBA. The participation agreement is completed as follows:

Name(s) and Address of Participant
Type or print the name and address of the new provider entity under which you will be receiving Medicare reimbursement.

Physician or Supplier Identification Code(s)
Indicate your new Medicare number (PTAN). If your new provider number is pending, enter your tax identification or social security number.

Effective Date
Enter the date the CMS-460 is being delivered or being mailed to the Medicare carrier or A/B MAC. Beginning of Agreement is the date you are mailing your participation agreement to the Medicare carrier or A/B MAC.

Signature of Participant or Authorized Representative of Participating Organization
This section needs a provider's signature or authorized representative.

Title
This section needs the title of provider (M.D., etc.) or representative.

Date
This section needs the date the agreement is signed.

Office Phone Number
This section needs the phone number of the practice.

Received By, Effective Date, Initials of Carrier Official
This section is completed by the Medicare carrier or A/B MAC.

Note:

  • Individual practitioners subject to mandatory assignment are not required to sign a CMS-460. Exception: CMS-460 is needed when practitioners are forming a group or are incorporated.
  • A group and all members must maintain the same participation status
  • Members joining a group are not required to sign a CMS-460

Send completed forms to:

 JJ Part BJM Part B 
Palmetto GBA
Part B Palmetto GBA
P.O. Box 100306
Columbia, SC 29202-3306 
Palmetto GBA
Part B Palmetto GBA
Mail Code: AG-310
P.O. Box 100190
Columbia, SC 29202-3190 

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Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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2008 PAR Agreement Form.pdf