- Determine if you will use PECOS or paper to enroll
- Enroll Using PECOS
-
Enroll Using Paper
- Determine your Business Structure
- Individual (Group Member) Reassigning Benefits Only
- Individual Medicare Enrollment Private Practice (Sole Proprietor) via SSN
- Individual Medicare Enrollment Private Practice (Sole Proprietor) via EIN
- Individual Medicare Enrollment Sole Owner of a Corporation via Tax ID
- Physician Assistant
- New Provider Corporation or Group (Multiple Owners)
- Ordering/Referring Provider Only
- Adding a New Reassignment of Benefits Using the CMS-855I
- Electronic Funds Transfer Agreement
- Medicare Participating Physician or Supplier Agreement
- Supporting Documents
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 and diploma for nonphysician practitioners
- Drug Enforcement Administration (DEA) Certification
- Business license
- Organizational Structure Diagram/Flowchart
- 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
- 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
Reviewed 6/13/2024
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:
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:
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