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Medicare Part [Change]
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Providers in AR, CO, LA, MS, NM, OK, TX, Indian Health & Veteran Affairs

Medicare Enrollment Forms (CMS-855)

Download, View, Fill & Print Forms

Don't want to use paper, print and mail? You can also enroll in Medicare by filling out these forms electronically, online, using Internet Based-PECOS at the CMS website.

Paper forms must be completed by all providers of services and suppliers of medical and other health services for enrollment in the Medicare program.

The Medicare program uses the same forms (listed below) for new enrollment, revalidations, or changes to your existing enrollment information (practice name, address, etc.)

Part B (Physicians/Providers)

Form Number

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CMS-855B

Clinics / Group Practices and Certain Other Suppliers

Clinics and group practices can apply for enrollment in the Medicare program or make a change to their existing enrollment information using the CMS-855B. Complete this application if you are an organization/group that plans to bill Medicare and you are:

A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, and portal x-ray suppliers).
A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.
Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction.
Currently enrolled in Medicare and need to make changes to your existing enrollment data.

Tutorial

CMS-855I

Physicians and Non-Physician Practitioners

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855I. Complete this application if you are an individual practitioner who plans to bill Medicare and you are:

An individual practitioner who will provide services in a private practice.
An individual practitioner who will provide services in a group setting.
Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction.
Currently enrolled in Medicare and need to make changes to your existing enrollment information.
An individual who has formed a professional corporation, professional association, limited liability company, etc., of which you’re the sole owner.

Tutorial

CMS-855O

Ordering and Referring Physicians and Non-Physician Practitioners

Physician and non-physician practitioners can apply to register for the sole purpose of ordering and referring items and/or services to Medicare beneficiaries or make a change in their registration using the CMS-855O. These physicians and non-physician practitioners do not and will not send claims to a Medicare Administrative Contractor for the services they furnish for reimbursement.

Tutorial

CMS-855R

Reassignment of Medicare Benefits

Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. Reassigning your Medicare benefits allows an eligible organization/group to submit claims and receive payment for Medicare Part B services that you have provided as a member of the organization/group. Such an eligible organization/group may be an individual, a clinic/group practice, or other health care organization. A separate CMS-855R must be submitted for each organization/group where a reassignment is being established or terminated.

Please note: Physician Assistants and Sole Owners do not complete the CMS-855R application for reassignment because the information is reported on the CMS-855I application.

Tutorial

CMS-588

Electronic Funds Transfer Agreement

This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking.

Tutorial

CMS-460

Medicare Participation Agreement

Used to enroll or change your participating status with the Medicare Program.

 


Part A (Facilities)

Form Number

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CMS-855A

Institutional Providers

Institutional providers can apply for enrollment in the Medicare program or make a change in their existing enrollment information using the CMS-855A. Complete this application if you are a health care organization and you plan to bill Medicare for Part A medical services or would like to report a change to your existing Part A enrollment data.

Tutorial

CMS-588

Electronic Funds Transfer Agreement

This form is used to have your Medicare payments deposited directly into your bank account. It eliminates paperwork and saves time by reducing routine banking.

Tutorial


Mailing Addresses

Mail completed forms, including an original signature and all supporting documentation to Novitas Solutions. Our mailing addresses are:

Jurisdiction L

Jurisdiction H

Indian Health Services

View Mailing Addresses for Pennsylvania, New Jersey, Maryland, Delaware, and the District of Columbia

View Mailing Addresses for Arkansas, Colorado, Louisiana, Mississippi, Oklahoma, New Mexico, Texas

View the Mailing Address for Indian Health Services


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Last modified:  10/30/2017