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Medicare Fee-For-Service Provider/Supplier Enrollment
ANNOUNCEMENTS & 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 FILLER
The 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)
- Electronic version or PDF version (1,234 KB) HealthCare Providers that will bill Medicare fiscal intermediaries (CMS 855A)
- Electronic version or PDF version (1,458 KB) HealthCare Providers that will bill Medicare carriers (CMS 855B)
- Electronic version or PDF version(781 KB) Individual Health Care Practitioners (CMS 855I)
- Electronic version or PDF version (310 KB) Individual Reassignment of Benefits (CMS 855R)
- Electronic version or PDF version (892 KB) DMEPOS Suppliers (CMS 855S)
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:
- Medicare authorization agreement for electronic funds transfers (Form CMS 588 - PDF File, 425 KB);
- Medicare Participating Physician or Supplier Agreement (Form CMS 460 - PDF File, 126 KB); and
- Electronic Data Interchange (EDI) Agreement - PDF File, 9 KB
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.
| Note: Some of the files on this page are available only in Adobe Acrobat - Portable Document Format (PDF). To view PDF files, you must have the Adobe Acrobat Reader (minimum version 5, version 6 suggested). You can check here to see if you have the Acrobat Reader installed on your computer. If you do not already have the Acrobat Reader installed, please go to Adobe's Acrobat download page now. |
