- Determine if you Will Use PECOS or Paper to Revalidate
- Submit Revalidation Using PECOS
- Submit Revalidation Using Paper
- Clinics/Group Practices and Other Suppliers
- Physicians and Nonphysician Practitioners in Private Practice (Sole Owner or Sole Proprietor) With or Without any Reassigned Benefits
- Physicians and Nonphysician Practitioners that Reassign All Benefits
- Electronic Funds Transfer Agreement
- Supporting Documents
Clinics/Group Practices and Other Suppliers
Download CMS-855B.
- Complete Sections: 1, 2, 3, 4, 5, 6, 8, 13, 15B and D (if applicable)
- Attachment 1 for Ambulance Suppliers
- Attachment 2 for IDTFs
- Attachment 3 for OTP
Notes
- Individual physician/nonphysician practitioner will receive their own revalidation notice.
- Section 5 requires an organizational structure diagram/flowchart identifying all the entities listed and their relationships with the provider and each other.
- Be sure to include supporting documents such as IRS CP 575 or 147C that displays the legal business name and TIN/EIN.
- Contact your local state department to ensure you have met all state regulations and requirements.
Download and complete CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement.
Related Content
- CMS-855B Completion Tips for Ownership Interest and/or Managing Control Information
- Prevent Revalidation Processing Delays
- Supporting Documentation Required for Enrollment Revalidations
- Revalidation Application Checklist
Revised 11/1/2023
Helpful Resources
Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee
J6 Mailing Address:
National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475
Interactive Voice Response:
877-908-9499
Contact Enrollment:
877-908-8476
Hours Available:
Monday–Friday
8:00 a.m.–4:00 p.m. CT
Form(s) you'll need:
Helpful Resources
Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee
JK Mailing Address:
National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149
Interactive Voice Response:
877-869-6504
Contact Enrollment:
888-379-3807
Hours Available:
Monday–Friday
8:00 a.m.–4:00 p.m. ET
Form(s) you'll need: