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CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

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Enrollment Application Forms

You have two options for submitting your Part B Enrollment application to Medicare. You can choose to submit:

  1. Electronic application through PECOS, or
  2. CMS paper application forms

Determine Which Form(s) you Need

  • CMS-855B ‒ Medicare Enrollment Application for clinical/group practices. This form is used to initially enroll, revalidate or make change(s) to the existing Medicare enrollment information for clinic or groups.
     
  • CMS-855I ‒ Medicare Enrollment Application used by individual physicians or nonphysician practitioners to initiate the Medicare enrollment and/or revalidation process. This form is also used to make any change(s) to the existing Medicare enrollment information for individual physicians or nonphysician practitioners.
     
  • CMS-855O ‒ Medicare Enrollment Application for Eligible ordering and referring physicians and nonphysician practitioners enrolling in the Medicare Program for the sole purpose of ordering/referring specific items or services for Medicare beneficiaries or to change Medicare enrollment information.
     
  • CMS-855R ‒ Medicare Enrollment Application for physicians and nonphysician practitioners that reassign their benefits to another entity.
     
  • CMS-460Medicare Participating Physician/Supplier agreement form is completed if you wish to participate in the Medicare Program as a participating provider or supplier.
     
  • CMS-588 EFTAuthorization Agreement is mentioned as required documentation if you are not already receiving payments electronically. As noted in the documentation section, you will have to send additional information with this form.

  • CMS 20134 - Medicare Enrollment Application used by MDPP suppliers. This form is used to initially enroll, revalidate or make change(s) to the existing Medicare enrollment information for MDPP suppliers.

Revised 3/12/2019


Enrollment Application Forms
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