Form CMS-855I

Medicare Enrollment Application

CMS_855I_CHECK_DONE_FINAL

Medicare Enrollment Application

OMB: 0938-0685

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0685 can be found here:

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MEDICARE ENROLLMENT APPLICATION

PHYSICIANS AND

NON-PHYSICIAN PRACTITIONERS

CMS-855I

SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION.
SEE PAGE 2 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION.

SEE PAGE 27 TO FIND THE LIST OF THE SUPPORTING DOCUMENTATION

THAT MUST BE SUBMITTED WITH THIS APPLICATION.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0685

WHO SHOULD COMPLETE THIS APPLICATION
All physicians, as well as all non-physician practitioners listed below, must complete this application to
initiate the enrollment process:
Anesthesiology Assistant
Clinical social worker
Physician assistant
Audiologist
Mass immunization roster biller
Psychologist, Clinical
Certified nurse midwife
Nurse practitioner
Psychologist billing
Certified registered nurse
Occupational therapist in
independently
anesthetist
private practice
Registered Dietitian or
Clinical nurse specialist
Physical therapist in
Nutrition Professional
private practice
If your supplier type is not listed above, contact the fee-for-service contractor before you submit
this application.
Complete this application if you are an individual practitioner who plans to bill Medicare and you are:
• An individual practitioner who will provide services in a private setting.
• An individual practitioner who will provide services in a group setting. If you plan to render all of
your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17
of this application.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for
service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory
serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you
have added or changed a practice location).
• An individual who has formed a professional corporation, professional association, limited liability
company, etc., of which you are the sole owner.
If you provide services in a group/organization setting, you will also need to complete a separate
application, the CMS-855R, to reassign your benefits to each organization. If you terminate your
association with an organization, use the CMS-855R to submit that change.
If you perform diagnostic testing, you may be required to enroll as an Independent Diagnostic Testing
Facility (IDTF) if substantial portions of your diagnostic tests (other than clinical laboratory or pathology)
are provided to patients who are not your patients. Check with your Medicare fee-for-service contractor to
determine whether or not you need to enroll as an IDTF. If you only furnish diagnostic tests, claims must
be submitted as an IDTF and you must complete and submit the CMS-855B.
BILLING NUMBER INFORMATION

The Medicare Identification Number, often referred to as a Provider Identification Number (PIN), is a
generic term for any number other than the National Provider Identifier (NPI) that is used by a supplier to
bill the Medicare program.
The NPI is the standard unique health identifier for health care providers and is assigned by the National
Plan and Provider Enumeration System (NPPES). As a Medicare healthcare supplier, you must obtain
an NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enroll
ment information. Applying for the NPI is a process separate from Medicare enrollment. To obtain an
NPI, you may apply online at https://NPPES.cms.hhs.gov. For more information about NPI enumeration,
visit www.cms.hhs.gov/NationalProvIdentStand.

CMS-855I (10/07)

INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION

• Type or print all information so that it is legible. Do not use pencil.
• Report additional information within a section by copying and completing that section for each
additional entry.
• Attach all required supporting documentation.
• Keep a copy of your completed Medicare enrollment package for your own records.
• Send the completed application with original signatures and all required documentation to your
designated fee-for-service contractor.
AVOID DELAYS IN YOUR ENROLLMENT

To avoid delays in the enrollment process, you should:
• Complete all required sections.
• Ensure that the correspondence address shown in Section 2 is the supplier’s address.
Note: Do not enter a billing agent correspondence address in Section 2.
• Enter your NPI in the applicable section.
• Enter all applicable dates.
• Send the completed application with all supporting documentation to your designated fee-for-service contractor.
ADDITIONAL INFORMATION

For additional information regarding the Medicare enrollment process, visit
www.cms.hhs.gov/MedicareProviderSupEnroll.
The fee-for-service contractor may request, at any time during the enrollment process, documentation to
support and validate information reported on the application. You are responsible for providing this
documentation in a timely manner.
The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4)
and/or (b)(6), respectively. For more information, see the last page of this application to read the Privacy
Act Statement.
MAIL YOUR APPLICATION

The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative contractor
that services your State is responsible for processing your enrollment application. To locate the mailing
address for your fee-for-service contractor, go to www.cms.hhs.gov/MedicareProviderSupEnroll.

CMS-855I (10/07)

SECTION 1: BASIC INFORMATION

This section captures information regarding the reason you are submitting this application. Read this
section in full prior to indicating the reason for submission on page 4.
NEW ENROLLEES TO MEDICARE

If you are:
• Enrolling in the Medicare program for the first time with this particular Medicare fee-for-service
contractor.
• A physician assistant whose services are reimbursed through your employer would complete this

application. However, he/she would not complete the CMS 855R.

NOTE: A physician assistant should only complete Sections 1, 2, 3, 13, 15 and 17, and should report
all employers in Section 2E.
ENROLLED MEDICARE SUPPLIERS

The following actions apply to Medicare suppliers already enrolled in the program.
Enrolling with another fee-for-service contractor
If you are already enrolled with a Medicare fee-for-service contractor but are establishing a practice
location in another fee-for-service contractor’s jurisdiction.
Reactivation
To reactivate your Medicare billing privileges, submit this enrollment application. In addition, you must be
able to submit a valid claim and meet all current requirements for your supplier type
Voluntary Termination
You should voluntarily terminate your Medicare enrollment if you:
• Will no longer be rendering services to Medicare patients, or
• Are planning to cease (or have ceased) operations. A. National Provider Identifier (NPI)
Change of Information
If you are adding, deleting, or changing information you previously reported to Medicare.
If you are already in Medicare and are not receiving Medicare payments via EFT, any change to your
enrollment information will require you to submit a CMS-588 form. All future payments will then be
received via EFT.
Changes in your existing enrollment data must be reported to the fee-for-service contractor in
accordance with 42 CFR § 424.520(b).
Revalidation
CMS may require you to submit or update your enrollment information. The fee-for-service contractor will
notify you when it is time for you to revalidate your enrollment information. Do not submit a revalidation
application until you have been contacted by the fee-for-service contractor.

CMS-855I (10/07)

SECTION 1: BASIC INFORMATION

A. Check one box and complete the required sections.
Since physician assistants do not complete Section 4, all physician assistants must furnish their Medicare
Identification Number (if issued) and their NPI here:
Medicare Identification Number(s):_______________________ NPI:_______________________
If you are reassigning all of your Medicare benefits per section 4B1 of this application, furnish your
Medicare Identification Number (if issued) and your NPI here:
Medicare Identification Number(s):_______________________ NPI:_______________________
REASON FOR APPLICATION

BILLING NUMBER INFORMATION

❏ You are a new enrollee in Medicare

Enter your Medicare
Identification Number (if
issued) and the NPI you would
like to link to this number in
Section 4.

Complete all sections

❏ You are enrolling with another
fee-for-service contractor

Enter your Medicare
Identification Number (if
issued) and the NPI you would
like to link to this number in
Section 4.

Complete all sections

❏ You are reactivating your
Medicare enrollment

Enter your Medicare
Identification Number (if
issued) and the NPI you would
like to link to this number in
Section 4.

Complete all sections

Effective Date of Termination

Sections 1A, 13 and 15

❏ You are voluntarily terminating
your Medicare enrollment

Medicare Identification
Number(s) to Terminate
(if issued):
National Provider Identifier
(if issued):

CMS-855I (10/07)

REQUIRED SECTIONS

Physician Assistants must
complete Sections 1A, 2F, 13
and 15
Employers terminating
Physician Assistants must
complete Sections 1A, 2G, 13
and 15
4

SECTION 1: BASIC INFORMATION

❏ You are changing your
Medicare information

(Continued)

Medicare Identification
Number (if issued):

Go to Section 1B

NPI:

❏ You are revalidating your
Medicare enrollment

Enter your Medicare
Identification Number (if
issued) and the NPI you would
like to link to this number in
Section 4.

Complete all sections

B. Check all that apply and complete the required sections.
REQUIRED SECTIONS

❏ Identifying Information

1, 2 (complete only those sections that
are changing), 3, 13 and 15

❏ Adverse Legal Actions / Convictions

1, 2A, 3, 13 and 15

❏ Practice Location Information, Payment Address
and Medical Record Storage Information

1, 2A, 3, 4 (complete only those sections
that are changing), 13 and 15

❏ Individuals Having Managing Control

1, 2A, 3, 6, 13, and 15

❏ Billing Agency Information

1, 2A, 3, 8 (complete only those sections
that are changing), 13 and 15

CMS-855I (10/07)

SECTION 2: IDENTIFYING INFORMATION

A. Personal Information: Your name, date of birth, and social security number must coincide with the
information on your social security record.
1. First Name

Middle Initial Last Name

Jr., Sr., M.D., D.O., etc.

2. Other Name, First

Middle Initial Last Name

Jr., Sr., M.D., D.O., etc.

Type of Other Name

❏ Former or Maiden Name ❏ Professional Name ❏ Other (Describe):____________________________________
Date of Birth
3. Gender
❏ Male

(mm/dd/yyyy)

State of Birth

Country of Birth
4. Social Security Number

❏ Female

Medical or other Professional School (Training Institution, if non-MD)

Year of Graduation (yyyy)

DEA Number (if applicable)

License Information
❏ License Not Applicable
License Number

State Where Issued

Effective Date (mm/dd/yyyy)

Expiration/Renewal Date (mm/dd/yyyy)

Certification Information
❏ Certification Not Applicable
Certification Number

State Where Issued

Effective Date (mm/dd/yyyy)

Expiration/Renewal Date (mm/dd/yyyy)

B. Correspondence Address
Provide contact information for the person shown in Section 2A above. Once enrolled, the information
provided below will be used by the fee-for-service contractor if it needs to contact you directly. This
address cannot be a billing agency’s address.
Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Suite, Room, etc.)
City/Town
Telephone Number

CMS-855I (10/07)

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

C. Resident/Fellow Status
1. Are you currently in an approved training program as:
a. A resident?
b. In a fellowship program?

❏ YES ❏ NO
❏ YES ❏ NO

• If NO, skip to Section 2D.
• If YES to either of the above questions, provide the name and address of the facility

where you are a resident or fellow on the following lines:

______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
2. Are the services that you render at the facility shown in Section 2C1
part of your requirements for graduation from a formal residency
or fellowship program?

❏ YES ❏ NO

Date of Completion:____________. If your completion date is prior to the beginning date for your
practice in Section 4, skip to Section 2D.
3. Do you also render services at other facilities or practice locations?
IF YES, you must report these practice locations in Section 4.

❏ YES ❏ NO

4. Are the services that you render in any of the practice locations you will
be reporting in Section 4 part of your requirements for graduation from
a residency or fellowship program?

❏ YES ❏ NO

IF YES, has the teaching hospital reported in Section 2C1 above agreed to
incur all or substantially all of the costs of training in the non-hospital facility
or location?

❏ YES ❏ NO

CMS-855I (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

D. Medical Specialties
1. PHYSICIAN SPECIALTY
Designate your primary specialty and all secondary specialty(s) below using:
P=Primary S=Secondary
You may select only one primary specialty. You may select multiple secondary specialties. A physician
must meet all Federal and State requirements for the type of specialty(s) checked.

■ Addiction medicine
■ Allergy/Immunology
■ Anesthesiology
■ Cardiac surgery
■ Cardiovascular disease

■ Hematology
■ Hematology/Oncology
■ Infectious disease
■ Internal medicine
■ Interventional Pain

■ Otolaryngology
■ Pathology
■ Pediatric medicine
■ Peripheral vascular disease
■ Physical medicine

(Cardiology)

■ Chiropractic
■ Colorectal surgery

(Proctology)

■ Critical care (Intensivists)
■ Dermatology
■ Diagnostic radiology
■ Emergency medicine
■ Endocrinology
■ Family practice
■ Gastroenterology
■ General practice
■ General surgery
■ Geriatric medicine
■ Gynecological oncology
■ Hand surgery

Management

■ Interventional radiology
■ Maxillofacial surgery
■ Medical oncology
■ Nephrology
■ Neurology
■ Neuropsychiatry
■ Neurosurgery
■ Nuclear medicine
■ Obstetrics/Gynecology
■ Ophthalmology
■ Optometry
■ Oral surgery (Dentist only)
■ Orthopedic surgery
■ Osteopathic

manipulative treatment

and rehabilitation

■ Plastic and

reconstructive surgery

■ Podiatry
■ Preventive medicine
■ Psychiatry
■ Pulmonary disease
■ Radiation oncology
■ Rheumatology
■ Surgical oncology
■ Thoracic surgery
■ Urology
■ Vascular surgery
■ Undefined physician type
(Specify):__________________

Diagnostic Radiology–If you checked diagnostic radiology as your specialty and you will bill for the
technical component of the diagnostic tests, you must contact the Medicare fee-for-service contractor prior
to your enrollment to determine if you will also need to complete a CMS 855B to enroll in Medicare as an
Independent Diagnostic Testing Facility (IDTF).
Physicians who bill for diagnostic tests (other than clinical laboratory or pathology tests)–
As a physician, you may bill for these diagnostic tests as long as you do not provide a substantial portion of
the diagnostic tests to patients who are not your own patients. Patients are considered your own patients if:
• They have a prior relationship with you and are receiving medical treatment from you for a

specific medical condition, or

• You are also billing for patient evaluation and management (E & M) codes.

CMS-855I (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

2. NON–PHYSICIAN SPECIALTY
If you are a non-physician practitioner, check the appropriate box to indicate your specialty.
All non-physician practitioners must meet specific licensing, educational, and work experience requirements.
If you need information concerning the specific requirements for your specialty, contact the Medicare feefor-service contractor.
Check only one of the following: If you want to enroll as more than one non-physician specialty type,
you must submit a separate CMS-855I application for each.
■ Physical therapist in private practice
■ Anesthesiology assistant
■ Physician assistant
■ Audiologist
■ Psychologist, clinical
■ Certified nurse midwife
■ Psychologist billing independently
■ Certified registered nurse anesthetist
■ Registered dietitian or nutrition professional
■ Clinical nurse specialist
■ Undefined non-physician practitioner type (Specify):
■ Clinical social worker
_______________________________________
■ Mass immunization roster biller
_______________________________________
■ Nurse practitioner
_______________________________________
■ Occupational therapist in private practice

CMS-855I (10/07)

SECTION 2: IDENTIFYING INFORMATION

(Continued)

E. Physician Assistants: Establishing Employment Arrangement(s)
Employer’s Name

Effective Date
of Employment

Employer’s Medicare
Identification Number (if issued)

Employer’s NPI

F. Physician Assistants: Terminating Employment Arrangement(s)
Complete this section if you are a physician assistant discontinuing your employment with a practice.
Employer’s Name

Effective Date
of Departure

Employer’s Medicare
Identification Number (if issued)

Employer’s NPI

G. Employer Terminating Employment Arrangement With One or More Physician Assistants
This section should be used by an individual who has incorporated or is a sole proprietor, and who is
discontinuing their employment arrangement with a physician assistant.
Physician Assistant’s Name

CMS-855I (10/07)

Effective Date of
Departure

Physician Assistant’s Medicare
Identification Number (if issued)

Physician Assistant’s NPI

SECTION 2: IDENTIFYING INFORMATION

(Continued)

H. Clinical Psychologists
Do you hold a doctoral degree in psychology?
If YES, furnish the field of your psychology degree__________________________

❏ YES

❏ NO

❏ YES

❏ NO

❏ YES
❏ YES

❏ NO
❏ NO

❏ YES

❏ NO

❏ YES

❏ NO

❏ YES

❏ NO

Attach a copy with this application.
I. Psychologists Billing Independently
1. Do you render services of your own responsibility free from the administrative
control of an employer such as a physician, institution, or agency?
2. Do you treat your own patients?
3. Do you have the right to bill directly, and to collect and
retain the fee for your services?
4. Is this private practice located in an institution?
If YES to question 4 above, please answer questions “a” and “b” below.
a) If your private practice is located in an institution, is your office confined
to a separately identified part of the facility that is used solely as your office
and cannot be construed as extending throughout the entire institution?
b) If your private practice is located in an institution, are your services also
rendered to patients from outside the institution or facility where your
office is located?
J. Physical Therapists/Occupational Therapists in Private Practice (PT/OT)
The following questions only apply to your individual practice. They do not apply if you are reassigning
all of your benefits to a group/organization.
1. Are all of your PT/OT services only rendered in the patients’ homes?
❏ YES
❏ NO
2. Do you maintain private office space?
❏ YES
❏ NO
3. Do you own, lease, or rent your private office space?
❏ YES
❏ NO
4. Is this private office space used exclusively for your private practice?
❏ YES
❏ NO
5. Do you provide PT/OT services outside of your office and/or patients’ homes?
❏ YES
❏ NO
If you respond YES to any of the questions 2–5 above, attach a copy of the lease agreement that gives
you exclusive use of the facility for PT/OT services.
K. Nurse Practitioners and Certified Clinical Nurse Specialists
Are you an employee of a Medicare skilled nursing facility (SNF) or of another
entity that has an agreement to provide nursing services to a SNF?

❏ YES

❏ NO

If yes, include the SNF’s name and address.
Name
Street Address
City

CMS-855I (10/07)

State

Zip

SECTION 3: ADVERSE LEGAL ACTIONS/CONVICTIONS

This section captures information on adverse legal actions, such as convictions, exclusions, revocations,
and suspensions. All applicable adverse legal actions must be reported, regardless of whether any records
were expunged or any appeals are pending. If you are uncertain as to whether a name reported on this
application has an adverse legal action, query the Healthcare Integrity and Protection Data Bank. For
information on how to access the Data Bank, call 1-800-767-6732 or visit www.npdb-hipdb.com. There is a
charge for using this service.
ADVERSE LEGAL ACTIONS THAT MUST BE REPORTED
Convictions
1. The provider, supplier, or any owner of the provider or supplier was, within the last 10 years preceding
enrollment or revalidation of enrollment, convicted of a Federal or State felony offense that CMS has
determined to be detrimental to the best interests of the program and its beneficiaries. Offenses include:
Felony crimes against persons and other similar crimes for which the individual was convicted,
including guilty pleas and adjudicated pre-trial diversions; financial crimes, such as extortion,
embezzlement, income tax evasion, insurance fraud and other similar crimes for which the
individual was convicted, including guilty pleas and adjudicated pre-trial diversions; any felony
that placed the Medicare program or its beneficiaries at immediate risk (such as a malpractice suit
that results in a conviction of criminal neglect or misconduct); and any felonies that would result
in a mandatory exclusion under Section 1128(a) of the Social Security Act.
2. Any misdemeanor conviction, under Federal or State law, related to: (a) the delivery of an item or
service under Medicare or a State health care program, or (b) the abuse or neglect of a patient in
connection with the delivery of a health care item or service.
3. Any misdemeanor conviction, under Federal or State law, related to theft, fraud, embezzlement,
breach of fiduciary duty, or other financial misconduct in connection with the delivery of a health
care item or service.
4. Any felony or misdemeanor conviction, under Federal or State law, relating to the interference with
or obstruction of any investigation into any criminal offense described in 42 C.F.R. Section
1001.101 or 1001.201.
5. Any felony or misdemeanor conviction, under Federal or State law, relating to the unlawful
manufacture, distribution, prescription, or dispensing of a controlled substance.
Exclusions, Revocations, or Suspensions
1. Any revocation or suspension of a license to provide health care by any State licensing authority.
This includes the surrender of such a license while a formal disciplinary proceeding was pending
before a State licensing authority.
2. Any revocation or suspension of accreditation.
3. Any suspension or exclusion from participation in, or any sanction imposed by, a Federal or
State health care program, or any debarment from participation in any Federal Executive Branch
procurement or non-procurement program.
4. Any current Medicare payment suspension under any Medicare billing number.
5. Any Medicare revocation of any Medicare billing number.

CMS-855I (10/07)

SECTION 3: ADVERSE LEGAL ACTIONS/CONVICTIONS (Continued)
ADVERSE LEGAL HISTORY
1. Have you, under any current or former name or business entity, ever had an adverse legal action
listed on page 12 of this application imposed against you?
❏ YES–Continue Below

❏ NO–Skip to Section 4

2. If yes, report each adverse legal action, when it occurred, the Federal or State agency or the
court/administrative body that imposed the action, and the resolution, if any.
Attach a copy of the adverse legal action documentation and resolution.
Adverse Legal Action

Date

Taken By

Resolution

____________________

___________________ ___________________ __________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

CMS-855I (10/07)

SECTION 4: PRACTICE LOCATION INFORMATION

A. Establishing a Professional Corporation, Professional Association,
Limited Liability Company, etc.
If you are the sole owner of a professional corporation, a professional association, or a limited liability
company, and will bill Medicare through this business entity, complete this section about the business entity.
Legal Business Name as Reported to the Internal Revenue Service

Tax Identification Number

Medicare Identification Number (if issued)

NPI

Incorporation Date (mm/dd/yyyy) (if applicable)

State Where Incorporated (if applicable)

ADVERSE LEGAL HISTORY (Please refer to page 12 in Section 3 before completing this section)
1. Has your organization, under any current or former name or business identity, ever had any of the
adverse legal actions listed on page 12 of this application imposed against it?
❏ YES–Continue Below

❏ NO–Skip to Section 4

Date

Taken By

Resolution

____________________

___________________ ___________________ __________________

________________________

_______________________ _______________________

_____________________

________________________

_______________________ _______________________

_____________________

A. PRACTICE LOCATION INFORMATION

If you are the sole owner of a professional corporation, a professional association, or a limited
liability company, and will bill Medicare through this business entity, skip to Section 4C and
complete the rest of the application about your business entity.
B. Individual Affiliations
Complete this section with information about your private practice and group affiliations.
Beginning with Section 4B1, answer “Yes” or “No” to each question. If you answer “yes” to any question,
furnish the requested information about each group/organization to which you will reassign your benefits.
In addition, either you or each group/organization reported in this section must complete and submit a CMS
855R(s) (Individual Reassignment of Benefits) with this application. Reassigning benefits means that you are
authorizing the group/organization to bill and receive payment from Medicare for the services you have
rendered at the group/organization’s practice location.
If you are the sole owner of a professional corporation, a professional association, or a limited liability
company, and will bill Medicare through this business entity, you do not need to complete a CMS-855R
that reassigns your benefits to the business entity.
If you are an individual who is reassigning all of your benefits to a group, neither you nor the group needs
to submit a CMS-588 (Electronic Funds Transfer) form to facilitate that reassignment.

CMS-855I (10/07)

SECTION 4: PRACTICE LOCATION INFORMATION (Continued)
1. Will all of your services be rendered as part of a group or organization to which you will
reassign your benefits?
❏ YES Furnish the name, Medicare identification number(s) and NPI of each group or organization
below and skip to Section 13.
❏ NO Proceed to Section 4B2 below.
a) Name of Group/Organization