The following information provides a review of all Centers for Medicare & Medicaid Services (CMS) forms used in the enrollment process, as well as a checklist of what additional information you will need when you apply.

CMS Electronic Medicare Enrollment Forms

• The CMS-855A form is completed by enrolling facilities or if there is a change of information pertaining to an entity that has been previously enrolled into the Medicare A program.
• The Application for Individual Health Care Practitioners (CMS-855I) form is used for individual enrollment, re-enrollment, and changes.
• The Application for Health Care Suppliers That Will Bill Medicare Carriers (CMS-855B) form is use for group or organization enrollment, re-enrollment, and changes to the CMS-855B form.
• The Application for Individual Health Care Practitioners to Reassign Medicare Benefits (CMS-855R) form is used when you are adding or deleting group affiliation of an individual.
• The Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588 [08/06]) form is completed to initiate the process to receive payments electronically.

Note: The CMS-855I and CMS-855R forms should be forwarded to the appropriate National Government Services office.

Completed forms should be mailed to your contractor.

Initial Application Checklist

The following items will be requested of any provider completing an initial application. The underlined items are required for any application submission.

• Medicare Provider Enrollment Application (CMS-855)
• Completed Authorization Agreement for Electronic Funds Transfers (CMS-588)
• Copy of the national provider identifier (NPI) notification that you received from the National Plan and Provider Enumeration System
• Exhibit 177 (for federally qualified health centers [FQHCs] only)
• Exhibit 178 (for FQHCs only)
• Copy of the HRSA Notice of Grant Award (for FQHCs only)
• Copy of Exhibit 5 form B listing the site covered under the Grant (for FQHCs only)
• Written confirmation from the Internal Revenue Service (IRS) confirming the Tax Identification number, IRS document (501[c] 3)
• Articles of Incorporation, Organization, or By Laws
• DBA Certification (if applicable)
• Licenses, certifications, and registration required by Medicare or federal and state law
• Federal, state, and/or local (city/county) business licenses, certifications, and/or registrations required to operate a health care facility
• Copy of all adverse legal action documentation (e.g., notifications, resolutions, and reinstatement letters)
• Copy of delegated officials W-2 (if applicable)
• Copy of an attestation for government entities and tribal organizations (if applicable)
• Copy of all applicable Clinical Laboratory Improvement Act (CLIA) certifications (if applicable)
• A list of Board of Directors

Please be aware that all CMS-855 Medicare enrollment applications received for initial enrollment (i.e., CMS-855A, CMS-855B, or CMS-855I), change to a provider/supplier file (CMS-855I or CMS-855B), and reassignment of Benefits (CMS-855R), will be returned to the applicant if it is incomplete or if required supporting documentation is not attached.

Reasons for Delay

• Application received without a signature or date
• Submission of an obsolete application (current version is 07/06)
• Submission of an incomplete application or lack of supporting documentation
• Lack of timely responses