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Medicare Fee-For-Service Provider/Supplier EnrollmentANNOUNCEMENTS & NEW INFORMATION:The new CMS 855 forms are available and no prior versions (i.e. 1/98 versions of Form HCFA-855) are being accepted effective immediately. See below for downloadable copies of the new forms.
Check contacts to determine where to submit the application. If you are unsure whether you should send it to a carrier or intermediary, check the Provider/Supplier List for your provider type.The CMS 855 forms listed below are in two file formats: Electronic version and PDF version. The electronic version is compatible with Windows 95 or above, Windows NT. It will allow you to complete the forms using your computer and to save your information for future use to report changes. It will provide real-time edit checks and instructions for completing the form. These forms can not be submitted electronically. They must be printed; the certification statement must be signed and dated, and mailed to the contractor for your locality. Please refer to the user's guide before accessing the forms. For your convenience, we have provided you with two versions of the user's guide: ELECTRONIC VERSION SOFTWARE - FORMATTA FILLERThe electronic versions of the CMS 855 forms require the Formatta Filler program to complete. Click Formatta Filler to download and install the software. The forms can not be completed or viewed without Formatta Filler. Please do not contact Formatta regarding questions about these forms. If you have difficulty downloading, installing, or accessing these forms, please refer to the comprehensive user's guide (PDF File, 937 KB) for detailed instructions. For additional assistance, please contact the contractor that services your geographical area. CMS 855 FORMS & CHECKLIST (PDF 79 KB)
ADDITIONAL FORMS
After completing the enrollment form, you can also download additional forms that often (and should) accompany the CMS 855 enrollment forms that will help facilitate other actions. Therefore prior to leaving our web site, we suggest you look at the following links to determine if they pertain to you. They include the following:
If you have any questions, please contact your local Medicare contractor.
Make note of your contractor's name and number. They will be glad
to assist you during the enrollment process.
Last Modified on Friday, September 17, 2004
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Centers for Medicare & Medicaid Services
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