Provider Enrollment
The Medicare provider enrollment application form  is an Office of Management and Budget approved form and is available in a PDF interactive form field format. These forms include the CMS-855A, CMS-855B, CMS-855I, CMS-855R, and CMS-855S. You can download and complete the application form on your computer, save it as a file, and then print the completed form for final signature and submission. You are not able to submit the forms electronically at this time.
Please mail completed CMS-855 Medicare enrollment forms to the following address as appropriate.
State |
Customer Service |
Address |
Illinois and Indiana |
317-841-4540 Eastern Time (ET) |
National Government Services, Inc.
P.O. Box 7078
Indianapolis, Indiana 46207-7078 |
Kentucky and Ohio |
513-852-4232 ET |
National Government Services, Inc.
P.O. Box 7141
Indianapolis, Indiana 46207-7141 |
Connecticut, Delaware, Massachusetts, New York |
888-855-4356 ET |
National Government Services, Inc.
P.O. Box 4846
Syracuse, New York 13202-4846 |
Maine, Massachusetts, New Hampshire, Vermont |
866-539-5593 ET |
National Government Services, Inc.
P.O. Box 4792
Syracuse, New York 13221-4792 |
Michigan, Virginia, West Virginia, Wisconsin |
414-459-6972 Central Time (CT) |
National Government Services, Inc.
P.O. Box 7149
Indianapolis, Indiana 46207-7149 |
Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon, Pacific Islands, and Washington |
805-367-0734 Pacific Time (PT) |
National Government Services, Inc.
P.O. Box 7143
Indianapolis, Indiana 46207 |
Freestanding federally qualified health centers except Arizona, Montana, North Dakota, Utah, & Wyoming |
414-459-6972 CT |
National Government Services, Inc.
P.O. Box 7149
Indianapolis, Indiana 46207-7149 |
Freestanding home health & hospice providers in the following states: Michigan, Minnesota, New Jersey, New York, Puerto Rico, Virgin Islands, Wisconsin |
414-459-6972 CT |
National Government Services, Inc.
P.O. Box 7149
Indianapolis, Indiana 46207-7149 |
Health care organization’s part of the Beverly chain and Total Renal Care/Davita |
805-367-0734 PT |
National Government Services, Inc.
P.O. Box 7143
Indianapolis, Indiana 46207 |
Contact your home state fiscal intermediary if your health care organization is one of the following provider types: comprehensive outpatient rehabilitation facility, community mental health center, critical access hospital, acute care hospital, renal dialysis center, rehabilitation center, rural health center, or skilled nursing facility
Page last modified: 11/16/2008
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