Provider Enrollment Forms

Provider/supplier enrollment is a critical function that attempts to ensure that only qualified, eligible individuals and entities are enrolled in the Medicare program and receive reimbursement for services furnished to beneficiaries.  These applications must be used by all providers of Medicare services within our jurisdiction, such as physicians, non-physician practitioners, and ambulance companies.  Please visit our Enrollment Process Instructions section for assistance in selecting the correct form to complete.

• (Form CMS-460) Medicare Participating Physician or Supplier Agreement
• (Form CMS - 588) Authorization Agreement for Electronic Funds Transfer (EFT) 
• (Form CMS-855A) Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries
  This application is to be completed by a provider (e.g., hospital) that will furnish medical services to Medicare beneficiaries and bill fiscal intermediaries.
• (Form CMS-855B) Application for Health Care Suppliers that will Bill Medicare Carriers
  This application is to be completed by a supplier (e.g., ambulance company, physician groups) that will bill Medicare carriers for medical services furnished to Medicare beneficiaries. It is not to be used to enroll individuals.
• (Form CMS-855I) Application for Individual Health Care Practitioners
  A physician or non-physician practitioner who renders medical services to Medicare beneficiaries must complete this application. This form is processed through the Medicare carrier.
• (Form CMS-855R) Individual Reassignment of Benefits
  An individual who renders services and seeks to reassign his/her benefits to an eligible entity must complete the Form CMS-855R for each entity eligible to receive reassigned benefits. The person must be enrolled in the Medicare program as an individual before reassigning his/her benefits. The Form CMS-855R may be submitted concurrently with the Form CMS-855.
• (Form CMS-855S) DMEPOS Supplier Application
  A supplier that wishes to enroll in the Medicare program and provide Medicare beneficiaries with durable medical equipment, prosthetics, orthotics, or supplies (DMEPOS) must complete the Form CMS-855S. The National Supplier Clearinghouse (NSC) is responsible for processing the application.

The Medicare Federal Health Care Provider/Supplier Enrollment Applications (Form CMS-855I, Form CMS-855R, Form CMS-855B, Form CMS-855A and Form CMS-855S) are forms issued by the Centers for Medicare and Medicaid Services (CMS) and approved by the Office of Management and Budget (OMB). These forms may not be altered in any way. The forms are used to collect general information about providers/suppliers/DMEPOS supplier to ensure that the applicant is qualified and eligible to enroll in the Medicare program. In some circumstances, this information is necessary to determine the proper amount of Medicare payment. This information may also be used in any litigation that may arise (e.g., the collection of overpayments).

For additional information on Provider Enrollment, please visit the CMS Provider Enrollment web site.

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