Form CMS-855(O) Medicare Enrollment Application - fOr EligiblE OrdEring

MEDICARE ENROLLMENT APPLICATION
For Eligible ordering and referring
Physicians and Non-physician practitioners

CMS-855O
SEE Page 1 to determine if you are completing the correct application.
See page 2 for information on where to mail this application.

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

Form Approved
OMB No. xxxx-xxxx

Who should complete this application
Physicians and non-physician practitioners can apply for enrollment for the sole purpose of ordering
and referring items and/or services to beneficiaries in the Medicare program or make a change in their
enrollment information using either:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• The paper enrollment application process (e.g., CMS 855O).

For additional information regarding the Medicare enrollment process, including Internet-based PECOS,
go to http://www.cms.gov/MedicareProviderSupEnroll.

Most physicians and non-physician practitioners enroll in the Medicare program to be reimbursed for the
covered services they furnish to Medicare beneficiaries. However, with the implementation of Section
6405 of the Affordable Care Act, CMS permits certain physicians and non-physician practitioners to enroll
in the Medicare program for the sole purpose of ordering or referring items or services for Medicare
beneficiaries. These physicians and non-physician practitioners do not and will not send claims to a
Medicare contractor for the services they furnish. The physicians and non-physician practitioners who may
wish to enroll in Medicare solely for the purpose of ordering and referring include, but are not limited to,
those who are:
• employed by the Department of Veterans
• employed by Federally Qualified Health
Affairs (DVA)
Centers (FQHC), Rural Health clinics (RHC)
or Critical Access Hospitals (CAH)
• employed by the Public Health Service (PHS)
• licensed residents and physicians in a fellowship
• employed by the Department of Defense
(DOD) Tricare
• dentists, including oral surgeons
• employed by IHS or tribal organizations
• pediatricians
CMS is not requiring these physicians and non-physician practitioners to send the CMS 460, “Medicare
Participating Physician or Supplier Agreement,” or the CMS 588, “Electronic Funds Transfer (EFT)
Authorization Agreement.”

Billing number information
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 an enrolling Medicare supplier, you must obtain
an NPI prior to enrolling in Medicare. Applying for the NPI is a process separate from Medicare
enrollment. To obtain an NPI, you may apply online at https://NPPES.cms.gov. For more information
about NPI enumeration, visit www.cms.gov/NationalProvIdentStand.

The Medicare Identification Number, often referred to as a Provider Transaction Access Number (PTAN)
or Medicare legacy number, is a generic term for an identifier that Medicare assigns to its enrolled
providers and suppliers.

Instructions for Completing and Submitting this Application
• Type or print all information so that it is legible. Do not use pencil.

• Keep a copy of your completed Medicare enrollment application and any supporting data for your
own records.

• Send the completed application with original signatures to your designated Medicare fee-for-service
contractor.
• Sign and date the application in Section 6 (blue ink recommended).

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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 your address.
• Enter your NPI in the applicable section.
• Enter all applicable dates.

• Send the completed application to your designated fee-for-service contractor.

ADDITIONAL INFORMATION
For additional information regarding the Medicare enrollment process, visit www.cms.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.gov/MedicareProviderSupEnroll.

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SECTION 1: basic information

Check one box and complete the required sections.
Reason for application

NPI

You are enrolling for the sole purpose of
ordering/referring

Enter your NPI:

You are enrolled solely to order and refer and
are updating your information

Enter your NPI:

REQUIRED SECTIONS
Complete all sections
Complete all sections

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 First Name

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 (mm/dd/yyyy)

State of Birth

3. Gender

4. Social Security Number

Male

Country of Birth

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)

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 Medicare contractor if it needs to contact you directly. This address
cannot be a billing agency’s address. This address cannot be a billing address or P.O. Box.
Mailing Address Line 1 (Street Name and Number)
Mailing Address Line 2 (Apt. #)
City/Town

State

Telephone Number

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

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SECTION 2: Identifying Information (Continued)
C. Factor Requiring You to Enroll Solely to Order or refer
You are enrolling in Medicare solely to order or refer because you are (check one):
Employed by the DVA
Employed by the PHS
Employed by the DoD/Tricare
Employed by IHS or a Tribal Organization
Employed by a Medicare-enrolled FQHC
Employed by a Medicare-enrolled RHC
Employed by a Medicare-enrolled CAH
Physician not employed by any of the above
Non-physician practitioner not emplyed by any of the above
Licensed resident or fellow not employed at any of the above
Dentist not employed by any of the above
Pediatrician not employed by any of the above
Other (Specify):

_______________________________________________

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SECTION 2: Identifying Information (Continued)
D. Medical Specialties
1. Physician Specialty

If you are a physician, designate your primary specialty. A physician must meet all Federal and State
requirements for the type of specialty(s) checked.
Addiction medicine
Allergy/Immunology
Anesthesiology
Cardiac electrophysiology
Cardiac surgery
Cardiovascular disease (Cardiology)
Chiropractic
Colorectal surgery (Proctology)
Critical care (Intensivists)
Dermatology
Diagnostic radiology
Emergency medicine
Endocrinology
Family practice
Gastroenterology
General practice
General surgery
Geriatric medicine
Geriatric psychiatry
Gynecological oncology
Hand surgery
Hematology
Hematology/Oncology
Hospice
Infectious disease
Internal medicine
Interventional Pain 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 medicine
Otolaryngology
Pain Management
Palliative care
Pathology
Pediatric medicine
Peripheral vascular disease
Physical medicine and rehabilitation
Plastic and reconstructive surgery
Podiatry
Preventive medicine
Psychiatry
Pulmonary disease
Radiation oncology
Rheumatology
Sports medicine
Surgical oncology
Thoracic surgery
Urology
Vascular surgery
Unlisted physician type
(Specify):_________________________

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 fee-for-service contractor.
Check only one of the following:

Certified nurse midwife
Clinical nurse specialist
Clinical social worker
Nurse practitioner
Physician assistant
Clinical psychologist

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Psychologist billing independently
Unlisted non-physician practitioner type (Specify):
_____________________________
_____________________________
_____________________________
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SECTION 3: Final ADVERSE LEGAL ACTIONS/CONVICTIONS
This section captures information on final adverse legal actions, such as convictions, exclusions,
revocations, and suspensions. All applicable final adverse legal actions must be reported, regardless of
whether any records were expunged or any appeals are pending.
Convictions

1. The physician or non-physician practitioner was, within the last 10 years preceding enrollment or
revalidation of enrollment, convicted of a Federal or State felony offense that CMS has 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 Identification Number.
5. Any Medicare revocation of any Medicare Identification Number.

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SECTION 3: Final ADVERSE ACTIONS/CONVICTIONS (Continued)
Final ADVERSE HISTORY
1. Have you, under any current or former name or business identity, ever had a final adverse action
listed on page 6 of this application imposed against you?
YES–Continue Below

NO–Skip to Section 4

2. If yes, report each final adverse 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 final adverse action documentation and resolution.
Final Adverse Action

Date

Taken By

Resolution

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SECTION 4: CONTACT PERSON
This section captures information regarding the person you would like for us to contact regarding this
application. If no one is listed below, we will contact you directly at the Correspondence Address in
Section 2B.
First Name

Telephone Number

Middle Initial Last Name

Jr., Sr., etc.

Fax Number (if applicable)

E-mail Address (if applicable)

Address Line 1 (Street Name and Number)

Address Line 2 (Suite, Room, etc.)

City/Town

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State

ZIP Code + 4

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SECTION 5: PENALTIES FOR FALSIFYING INFORMATION
This section explains the penalties for deliberately furnishing false information in this
application to gain or maintain enrollment in the Medicare program.

1. 18 U.S.C. § 1001 authorizes criminal penalties against an individual who, in any matter within the
jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals
or covers up by any trick, scheme or device a material fact, or makes any false, fictitious, or fraudulent
statements or representations, or makes any false writing or document knowing the same to contain any
false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000
and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to
$500,000 (18 U.S.C. § 3571). Section 3571(d) also authorizes fines of up to twice the gross gain derived
by the offender if it is greater than the amount specifically authorized by the sentencing statute.
2. Section 1128B(a)(1) of the Social Security Act authorizes criminal penalties against any individual
who, “knowingly and willfully,” makes or causes to be made any false statement or representation of
a material fact in any application for any benefit or payment under a Federal health care program. The
offender is subject to fines of up to $25,000 and/or imprisonment for up to five years.
3. The Civil False Claims Act, 31 U.S.C. § 3729, imposes civil liability, in part, on any person who:
a) knowingly presents, or causes to be presented, to an officer or any employee of the United
States Government a false or fraudulent claim for payment or approval;
b) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false
or fraudulent claim paid or approved by the Government; or
c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of
damages sustained by the Government

4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including
an organization, agency or other entity) that knowingly presents or causes to be presented to an officer,
employee, or agent of the United States, or of any department or agency thereof, or of any State
agency…a claim…that the Secretary determines is for a medical or other item or service that the
person knows or should know:
a) was not provided as claimed; and/or
b) the claim is false or fraudulent.
5. This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an
assessment of up to three times the amount claimed, and exclusion from participation in the Medicare
program and State health care programs.

6. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care
benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or
device a material fact; or makes any materially false, fictitious, or fraudulent statements or representations,
or makes or uses any materially false fictitious, or fraudulent statement or entry, in connection with
the delivery of or payment for health care benefits, items or services. The individual shall be fined or
imprisoned up to 5 years or both.

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SECTION 5: PENALTIES FOR FALSIFYING INFORMATION (Continued)
7. 18 U.S.C. 1347 authorizes criminal penalties against individuals who knowing and willfully execute,
or attempt, to executive a scheme or artifice to defraud any health care benefit program, or to obtain,
by means of false or fraudulent pretenses, representations, or promises, any of the money or property
owned by or under the control of any, health care benefit program in connection with the delivery of or
payment for health care benefits, items, or services. Individuals shall be fined or imprisoned up to
10 years or both. If the violation results in serious bodily injury, an individual will be fined or imprisoned
up to 20 years, or both. If the violation results in death, the individual shall be fined or imprisoned for
any term of years or for life, or both.

8. The government may assert common law claims such as “common law fraud,” “money paid by
mistake,” and “unjust enrichment.”

Remedies include compensatory and punitive damages, restitution, and recovery of the amount of the
unjust profit.

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SECTION 6: CERTIFICATION STATEMENT

As an individual practitioner, you are the only person who can sign this application. The authority to sign
the application on your behalf may not be delegated to any other person.

The Certification Statement contains certain standards that must be met for initial and continuous
enrollment in the Medicare program solely to order and refer items and services for Medicare beneficiaries.
Review these requirements carefully.

By signing the Certification Statement, you agree to adhere to all of the requirements listed therein and
acknowledge that you may be denied entry to or revoked from the Medicare program if any requirements
are not met.
Certification Statement

You MUST sign and date the certification statement below in order to be enrolled in the Medicare program.
In doing so, you are attesting to meeting and maintaining the Medicare requirements stated below.
I, the undersigned, certify to the following:

1. I understand that in the future if I wish to be reimbursed by Medicare for services performed, I
must first submit the appropriate paper CMS-855 application or use Internet-based Pecos to
submit an enrollment application to the Medicare program.
2. I have read the contents of this application, and the information contained herein is true, correct, and
complete. If I become aware that any information in this application is not true, correct, or complete,
I agree to notify the Medicare fee-for-service contractor of this fact immediately.

3. I authorize the Medicare contractor to verify the information contained herein. I agree to notify the
Medicare contractor of a change in Section 2 information and/or Section 3 within 30 days of the
reportable event. In addition, I agree to notify the Medicare contractor of any other changes to the
information to this form within 90 days of the effective date of change. I understand that any change to
my status as an individual practitioner may require the submission of a new application.

4. I have read and understand the Penalties for Falsifying Information, as printed in this application.
I understand that any deliberate omission, misrepresentation, or falsification of any information
contained in this application or contained in any communication supplying information to Medicare,
or any deliberate alteration of any text on this application form, may be punished by criminal, civil,
or administrative penalties including, but not limited to the imposition of fines, civil damages,
and/or imprisonment.

5. I agree to abide by Medicare’s laws, regulations and program instructions. The Medicare laws,
regulations, and program instructions are available through the Medicare contractor. I understand
that payment of a claim by Medicare is conditioned upon the claim and the underlying transaction
complying with such laws, regulations, and program instructions (including, but not limited to, the
Federal anti-kickback statute and the Stark law), and on the supplier’s compliance with all applicable
conditions of participation in Medicare.
6. I will not knowingly present or cause to be presented a false or fraudulent claim for payment
by Medicare.

7. I further certify that I am the individual practitioner who is applying for the sole purpose of ordering
and referring items or services to Medicare beneficiaries.

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SECTION 6: CERTIFICATION STATEMENT (Continued)
First Name

Middle Initial

Last Name

Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)

M.D., D.O., etc.
Date Signed (mm/dd/yyyy)

All signatures must be original and signed in ink (blue ink preferred). Applications with signatures deemed
not original will not be processed. Stamped, faxed or copied signatures will not be accepted.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete
this information collection is estimated to 4 hours per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Medicare Supplier Enrollment Application PRIVACY ACT STATEMENT
The Centers for Medicare & Medicaid Services (CMS) is authorized to collect the information requested on this form
by sections 1124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42 U.S.C.
§§ 1320a-3(a)(1), 1320a-7, 1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt Collection
Improvement Act [31 U.S.C. § 7701(c)].
The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations
to enroll in the Medicare program as suppliers of goods and services to Medicare beneficiaries and to assist in the
administration of the Medicare program. This information will also be used to ensure that no payments will be made
to providers who are excluded from participation in the Medicare program. All information on this form is required,
with the exception of those sections marked as “optional” on the form. Without this information, the ability to make
payments will be delayed or denied.
The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
The information in this application will be disclosed according to the routine uses described below.

Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
2. A congressional office from the record of an individual health care provider in response to an inquiry from the
congressional office at the written request of that individual health care practitioner;
3. The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
4. Peer Review Organizations in connection with the review of claims, or in connection with studies or other review
activities, conducted pursuant to Part B of Title XVIII of the Social Security Act;
5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States
Government is a party to litigation and the use of the information is compatible with the purpose for which the
agency collected the information;
6. To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which
criminal penalties are attached;
7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when
the National Plan and Provider Enumeration System is unable to establish identity after matching contractor
submitted data to the data extract provided by the AMA;
8. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of
disease or disability, or to the restoration or maintenance of health;
9. Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers of
medical services or to detect fraud or abuse;
10. State Licensing Boards for review of unethical practices or non-professional conduct;
11. States for the purpose of administration of health care programs; and/or
12. Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health
care groups providing health care claims processing, when a link to Medicare or Medicaid claims is established,
and data are used solely to process supplier’s health care claims.
The supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503)
amended the Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through
computer matching.

Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this form is protected from public
disclosure by Federal law 5 U.S.C. § 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this application (or attachments thereto) constitutes a trade secret or privileged or
confidential information (as such terms are interpreted under the Freedom of Information Act and applicable case
law), or is of a highly sensitive personal nature such that disclosure would constitute a clearly unwarranted invasion
of the personal privacy of one or more persons, then such information will be protected from release by CMS under
5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.
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