Submit Enrollment Application

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:

Enrollment Forms

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:

Enrollment Forms

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