Skip to Main Content
 
 
 
Web Content Viewer

CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

Web Content Viewer
Web Content Viewer

Upload Supporting Documents

Instructions for PECOS to upload supporting documentation:

  • Select the ‘Topic View’ tab
  • Select “Required and/or Supporting Documents”
  • Verify documents and/or upload additional documents
Mandatory for all provider/supplier type:
  • Voided check or bank confirmation letter
  • IRS document such as the IRS-CP575 or IRS-147C that displays the legal business name and TIN/EIN

Note: Providers who are reassigning all of their payments to another entity are not required to submit these forms.

Mandatory for all provider/supplier types, if applicable

  • Medical license/certification
  • National certification for nonphysician practitioners
  • Business license
  • Accreditation
  • Final adverse legal action documentation
  • Application fee receipt or hardship exception request
  • Documentation verifying IDTF supervisory physician(s) proficiency and/or state licenses or certifications for IDTF nonphysician personnel
  • Documentation verifying state licenses or certifications of the laboratory director or nonphysician practitioner personnel of an independent clinical laboratory
  • FAA 135 certification (air ambulance suppliers)
  • Ambulance vehicle registration
  • Comprehensive liability insurance policy (IDTFs only)
  • Attestation for government entities and tribal organizations
  • IRS confirmation of Disregarded Entity
  • Lending relationship ‒ Statement in writing from the bank detailing agreement to waive its rights of offset for Medicare receivables

Note: If unable to upload supporting documentation, mail the documents.   

Related Content

Upload Supporting Documents
Web Content Viewer
Complementary Content