Submit Enrollment Application

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

Also view Understanding Authorized Official and Delegated Official Roles.

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, including add and terminate reassignment of benefits to a group/individual.
     
  • 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 Reassignment of Medicare Benefits.  This form was discontinued effective 10/31/2023, use the CMS-855I (5/23 version) to add, terminate or change reassignment information.
     
  • 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.

Please share your thoughts about your experience with our enrollment process. 

Revised 10/31/2023

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:

Enrollment Forms

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:

Enrollment Forms