Medicare Participating Physician or Supplier Agreement (CMS-460)

• Complete and submit the CMS-460 participation agreement with initial enrollment application (or within 90 days of initial enrollment) to become a participating provider.
• Complete and submit during open enrollment period from November 15 through December 31 of each year to become a participating provider.

Note: Completion of the CMS-460 is not applicable for clinical psychologists, clinical social workers, clinical nurse specialists, nurse practitioners, nurse midwives, physician assistants, certified registered nurse anesthetists, and dietitian/nutrition professionals, as these specialties are considered mandatory participation.

Organizations/Groups/PCs/LLCs/Partnerships

• Submit a copy of Internal Revenue Service (IRS) tax certificate (CP575), copy of coupon book cover, or letter from IRS

Individuals/Sole Proprietors (Not Incorporated)

• Submit a copy of state license
• Submit a copy of any certifications required for your specialty

Electronic Data Interchange Enrollment

• Complete the Electronic Data Interchange (EDI) Registration Form for New EDI Submitters to allow submission of Medicare claims electronically

Electronic Funds Transfer Request (CMS-588)

• Complete the CMS-588 form to have payments made directly to your bank account