Enrollment Application Forms

You have two options for submitting your Part B Enrollment application to Medicare. You can choose to submit:

1. Electronic application through PECOS, or
2. CMS paper application forms

Also view Understanding Authorized Official and Delegated Official Roles.

Determine Which Form(s) you Need

• CMS-855B ‒ Medicare Enrollment Application for clinical/group practices. This form is used to initially enroll, revalidate or make change(s) to the existing Medicare enrollment information for clinic or groups.


• CMS-855I ‒ Medicare Enrollment Application used by individual physicians or nonphysician practitioners to initiate the Medicare enrollment and/or revalidation process. This form is also used to make any change(s) to the existing Medicare enrollment information for individual physicians or nonphysician practitioners, including add and terminate reassignment of benefits to a group/individual.


• CMS-855O ‒ Medicare Enrollment Application for Eligible ordering and referring physicians and nonphysician practitioners enrolling in the Medicare Program for the sole purpose of ordering/referring specific items or services for Medicare beneficiaries or to change Medicare enrollment information.


• CMS-460 ‒ Medicare Participating Physician/Supplier Agreement form is completed if you wish to participate in the Medicare Program as a participating provider or supplier. This is for the billing provider/supplier enrollment only.


• CMS-588 EFT ‒ Authorization Agreement is mentioned as required documentation if you are not already receiving payments electronically. As noted in the documentation section, you will have to send additional information with this form.  This is for the billing provider/supplier enrollment only.


• CMS 20134 ‒ Medicare Enrollment Application used by MDPP suppliers. This form is used to initially enroll, revalidate or make change(s) to the existing Medicare enrollment information for MDPP suppliers.

Please share your thoughts about your experience with our enrollment process. 

Revised 6/14/2024