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.
Internet-based PECOS - supports the Medicare Provider and Supplier enrollment process by allowing registered users to securely and electronically submit and manage Medicare enrollment information
CMS 855B--Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers
CMS 855I --Medicare Enrollment Application for Physicians and Non-Physician Practitioners
CMS 855r--Medicare Enrollment Application for Reassignment of Medicare Benefits
CMS 855O--Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners
CMS 855S--Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
CMS 460--Medicare Participating Physician or Supplier Agreement
CMS 588--Electronic Funds Transfer (EFT) Registration Form
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: