- 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
Supporting Documents
Attach required supporting documentation for individuals or organizations.
Submit applicable documents:
- CMS-588 Electronic Funds Transfer (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)
- Medical license/certification
- National certification and diploma for nonphysician practitioners
- Drug Enforcement Administration (DEA) certification
- Business license
- Organizational Structure Diagram/Flowchart
- Final adverse legal action documentation
- Accreditation
- 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
- Mobile/Portable 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
- Supporting Documentation Required for Enrollment Revalidations
- Electronic Funds Transfer
- Electronic Funds Transfer Form and Instructions
Reviewed 7/30/2024
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: