Upload Supporting Documents

Instructions for PECOS to upload required supporting documentation:

• Select the ‘Topic View’ tab
• Select “Required and/or Supporting Documents”
• Upload documents

Mandatory for all provider/supplier types:

• Voided check or bank confirmation letter
• IRS document such as the IRS-CP575 or IRS-147C that displays the legal business name and TIN/EIN
  
  Note: Providers who are reassigning all of their payments to another entity are not required to submit these forms.

Mandatory for all provider/supplier types, if applicable:

• Medical license/certification
• National certification and diploma for nonphysician practitioners
• 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
• 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
• Comprehensive liability insurance policy (IDTFs only)
• Attestation for government entities and tribal organizations
• IRS confirmation of disregarded entity
• Lending relationship ‒ Statement in writing from the bank detailing agreement to waive its rights of offset for Medicare receivables

Note: If unable to upload supporting documentation, mail the documents with PECOS Web Tracking ID indicated on each page.

Related Content

• MLN Matters® SE1230: Addition of Digital Document Repository to Provider Enrollment Chain and Ownership System (PECOS)
• Digital Document Repository (DDR) How To Guide
• Supporting Documentation Required for Enrollment Revalidations

Reviewed 7/30/2024