Submit Enrollment Application

Supporting Documents

Attach required supporting documentation for individuals or organizations.

Submit all applicable documents:

  • CMS-588 EFT Authorization Agreement and voided check or bank confirmation letter
  • IRS document confirming your legal business name and EIN (e.g., IRS CP-575 or CP-147C)
  • Residency contract or confirmation from institutional official on resident status for unlicensed resident (CMS-855O)
  • Medical license/certification
  • National certification for nonphysician practitioners
  • Business license
  • Final adverse legal action documentation
  • Accreditation
  • CMS-460 Medicare Participating Physician or Supplier Agreement  
  • Application fee receipt or hardship exception request
  • Documentation verifying IDTF supervisory physician(s) proficiency and/or state licenses or certifications for IDTF nonphysician personnel
  • Comprehensive liability insurance policy (IDTFs only)
  • 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
  • Attestation for government entities and tribal organizations
  • IRS Form 8832 confirmation of disregarded entity
  • Lending relationship ‒ Statement in writing from the bank detailing agreement to waive its rights of offset for Medicare receivables

Related Content

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

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

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS

J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6474
Indianapolis, IN 46206-6474

Contact Enrollment:

855-834-5596

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT
9:00 a.m.–5:00 p.m. ET

*Closed for training on the 2nd and 4th Friday of the month
12:00 p.m.-4:00 p.m. ET
11:00 a.m.-3:00 p.m. CT

Form(s) you'll need:

CMS-855A - Medicare Enrollment Application form for Institutional Providers
CMS-588 - Electronic Funds Transfer (EFT) Authorization Agreement form

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 46206-7149

Contact Enrollment:

855-593-8047

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

*Closed for training on the 2nd and 4th Friday of the month
12:00 p.m.-4:00 p.m. ET

Form(s) you'll need:

CMS-855A - Medicare Enrollment Application form for Institutional Providers
CMS-588 - Electronic Funds Transfer (EFT) Authorization Agreement form