Form CMS-855O Medicare Registration Application

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MEdiCarE EnrOllMEnt aPPliCatiOn

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rEgiStratiOn fOr EligiblE OrdEring and rEfErring
PhySiCianS and nOn-PhySiCian PraCtitiOnErS

CMS-855O

SEE PagE 1 tO dEtErMinE if yOu arE COMPlEting thE COrrECt aPPliCatiOn
and fOr infOrMatiOn On whErE tO Mail thiS COMPlEtEd aPPliCatiOn.

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

Form Approved
OMB No. 0938-1135

whO ShOuld COMPlEtE thiS aPPliCatiOn
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 requires certain physicians and non-physician practitioners to register 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 Administrative
Contractor for the services they furnish. The physicians and non-physician practitioners who may register in
Medicare solely for the purpose of ordering and referring include, but are not limited to, those who are:
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employed by the Department of Veterans
Affairs (DVA)
employed by the Public Health Service (PHS)
employed by the Department of Defense
(DOD)/Tricare
employed by the Indian Health Service (IHS) or
a Tribal Organization

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employed by Federally Qualified Health Centers
(FQHC), Rural Health Clinics (RHC) or Critical Access
Hospitals (CAH)
licensed residents and physicians in a fellowship
dentists, including oral surgeons
pediatricians

Once registered, you will be placed on the Ordering and Referring Registry and will be deemed eligible to
order and refer patients to Medicare enrolled providers and suppliers.

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Physicians and non-physician practitioners can apply to register for the sole purpose of ordering and referring
items and/or services to beneficiaries in the Medicare program or make a change in their registration
information using either:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• Submit the paper CMS-855O application. Be sure you are using the most current version.
For additional information regarding the Medicare registration process, including Internet-based PECOS and
to get a copy of the most current CMS-855O application, go to https://www.cms.gov/MedicareProvider
SupEnroll.

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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. See the last page of this application to read the Privacy Act Statement.

natiOnal PrOvidEr idEntifiEr infOrMatiOn

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The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and
suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). as a registering
Medicare supplier, you must obtain an nPi prior to registering in Medicare. Applying for the NPI is a
process separate from Medicare registration. To obtain an NPI, you may apply online at https://nPPES.cms.
hhs.gov/nPPES/welcome.do. For more information about NPI enumeration, visit https://www.cms.gov/
nationalProvidentStand.

inStruCtiOnS fOr COMPlEting and SubMitting thiS aPPliCatiOn
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Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred.
Complete all applicable sections and furnish your NPI.
Keep a copy of your completed Medicare registration application for your records.
Sign and date the application in Section 8 using blue ink.

aCrOnyMS COMMOnly uSEd in thiS aPPliCatiOn
MaC: Medicare Administrative Contractor
nPi: National Provider Identifier

PECOS: Provider Enrollment Chain and Ownership
System
SSn: Social Security Number

whErE tO Mail yOur aPPliCatiOn
The MAC that services your State is responsible for processing your registration application. To locate the
mailing address for your designated MAC, go to https://www.cms.gov/MedicareProviderSupEnroll.
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SECtiOn 1: baSiC infOrMatiOn
Check one box and complete the required sections.
rEaSOn fOr aPPliCatiOn

rEQuirEd SECtiOnS

You are registering for the sole purpose of ordering/referring

Complete all sections

You are currently registered solely to order and refer and are
updating your information

Complete Section 2a, all other
applicable sections and Section 8

You are voluntarily withdrawing your Medicare registration to solely
order and refer

Complete Section 2a (name,
SSn and nPi) and Section 8
(Certification Statement)

SECtiOn 2: PErSOnal idEntifying infOrMatiOn
a. PErSOnal infOrMatiOn
Your name, date of birth, and social security number must match your social security record.
Middle Initial

Last Name

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

Other Name, First

Middle Initial

Last Name

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

Type of Other Name
Former or Maiden Name
Date of Birth (mm/dd/yyyy)

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First Name

Professional Name

Other (Describe):____________________________________

Place of Birth (State)

Gender

Male

Social Security Number (SSN)

Female

Medicare Identification Number (PTAN) (if issued) National Provider Identifier (NPI) (Type 1 – Individual)

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b. EduCatiOnal infOrMatiOn

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

Year of Graduation (yyyy)

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C. COrrESPOndEnCE Mailing addrESS

Once registered, the information provided below will be used by the MAC if it needs to contact you directly.
Mailing Address Line 1 (P.O. Box or Street Name and Number)

Mailing Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town

State

Telephone Number

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

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SECtiOn 3: final advErSE lEgal aCtiOnS
This section captures information regarding 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.

a. COnviCtiOnS

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1. If you were, within the last 10 years preceding enrollment/registration, convicted of a Federal or State
felony offense, you must report it in this section. Reportable offenses include, but are not limited to:
• 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.

b. ExCluSiOnS, rEvOCatiOnS Or SuSPEnSiOnS

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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 nonprocurement program.
4. Any past or current Medicare payment suspension under any Medicare billing number.
5. Any Medicare revocation of any Medicare billing number.

C. final advErSE lEgal aCtiOn hiStOry
If you are reporting a change to existing final adverse legal action information, check “Change,” provide the
effective date of the change, and complete the appropriate fields in this section.
Change

Effective date (mm/dd/yyyy): _______________________________

1. Have you, under any current or former name, ever had a final adverse legal action listed above imposed
against you?
YES–Continue Below

NO–Skip to Section 4

2. If yes, report each final 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.
final advErSE lEgal aCtiOn

datE

takEn by

rESOlutiOn

Attach a copy of the final legal adverse action documentation(s) and resolution(s).
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SECtiOn 4: MEdiCal SPECialty infOrMatiOn
a. PhySiCian SPECialtiES
Check your primary specialty below. Only check one (1) specialty. Physicians must meet all State requirements
for the type of specialty checked.
Neuropsychiatry
Neurosurgery
Nuclear medicine
Obstetrics/Gynecology
Ophthalmology
Optometry
Oral surgery (Dentist only)
Orthopedic surgery
Osteopathic manipulative medicine
Otolaryngology
Pain Management
Pathology
Pediatric medicine
Peripheral vascular disease
Physical medicine and rehabilitation
Plastic and reconstructive surgery
Podiatry
Preventive medicine
Psychiatry
Pulmonary disease
Radiation oncology
Rheumatology
Sleep Laboratory/Medicine
Sports medicine
Surgical oncology
Thoracic surgery
Urology
Vascular surgery
Unlisted physician type
(Specify):_________________________

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Addiction medicine
Allergy/Immunology
Anesthesiology
Cardiac electrophysiology
Cardiac surgery
Cardiovascular disease (Cardiology)
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 and Palliative Care
Infectious disease
Internal medicine
Interventional Pain Management
Interventional radiology
Maxillofacial surgery
Medical oncology
Nephrology
Neurology

b. nOn–PhySiCian SPECialtiES

If you are a non-physician practitioner, check the appropriate box to indicate your specialty.
All non-physician practitioners must meet specific licensing, certification, educational and work experience
requirements. If you need information concerning the specific requirements for your specialty, contact your
designated MAC.
Check only one of the following:
Certified nurse midwife
Clinical nurse specialist
Clinical psychologist
Clinical social worker

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Nurse practitioner
Physician assistant
Unlisted non-physician practitioner type (Specify):
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SECtiOn 5: Qualifying infOrMatiOn
a. liCEnSE/CErtifiCatiOn infOrMatiOn
1. license information
License Not Applicable
License Number

Effective Date (mm/dd/yyyy)

State Where Issued

Effective Date (mm/dd/yyyy)

State Where Issued

2. Certification information
Certification Not Applicable
Certification Number

3. drug Enforcement agency (dEa) information
Certification Not Applicable
DEA Number

Effective Date (mm/dd/yyyy)

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b. rEaSOn yOu arE rEgiStEring SOlEly tO OrdEr Or rEfEr

You are registering in Medicare solely to order or refer because you are (check one):

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Employed by the DVA
Employed by the PHS
Employed by the DOD/Tricare
Employed by the 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 employed 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 6: COntaCt PErSOn infOrMatiOn
Complete this section with information regarding a person you would like us to contact regarding this
application if you are not available. If no one is reported below, we will contact you directly at the
Correspondence Mailing Address in Section 2C.
First Name

Middle Initial

Last Name

Jr., Sr., MD., etc.

Address Line 1 (P.O. Box or Street Name and Number)
Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
Telephone Number

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

Relationship or Affiliation to You

nOtE: The Contact Person reported in this section will only be authorized to discuss issues concerning this
registration application. Your designated MAC will not discuss any other registration or enrollment issues
about you with the above Contact Person.

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SECtiOn 7: PEnaltiES fOr falSifying infOrMatiOn On thiS rEgiStratiOn
aPPliCatiOn
this section explains the penalties for deliberately furnishing false information in this application to gain or
maintain registration 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:

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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;

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

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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.

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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.
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 8: CErtifiCatiOn StatEMEnt and SignaturE
As an individual practitioner, you are the only person who can sign this application. The authority to sign this
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 registration
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 herein
and acknowledge that you may be denied or revoked from registering in the Medicare program if any
requirements are not met.

Certification Statement
You MuSt Sign and datE the certification statement below in order to be registered 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 if I wish to be reimbursed by Medicare for services I have performed, I must first enroll
in Medicare as an individual supplier using the CMS-855I.

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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 and complete, I
agree to notify my designated MAC immediately.
3. I authorize the MAC to verify the information contained herein. I agree to notify the MAC of any
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.

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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 and/
or administrative penalties including, but not limited to the imposition of fines, civil damages and/or
imprisonment.

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5. I agree to abide by all Medicare regulations, program instructions and Title XVIII of the Social Security
Act. The Medicare laws, regulations and program instructions are available through the MAC. 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 my compliance with all applicable
conditions of participation in Medicare.
6. I will not knowingly order and/or refer an item and/or service that allows a false or fraudulent claim to
be presented 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, and I have signed and dated this application.
First Name (Print)

Middle Initial

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

Last Name

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

all signatures must be original and signed in blue ink. applications with signatures deemed not original or
not dated will not be processed. Stamped, faxed or copied signatures will not be accepted.
nOtE: The Medicare Administrative Contractor (MAC) may request, at any time during the registration process,
documentation to support and validate information reported on the application. You are responsible for
providing this documentation in a timely manner, usually within 30 days.

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

MEdiCarE SuPPliEr rEgiStratiOn 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), 1128, and 1834(a)(11) of the Social Security Act.
The purpose of collecting this information is to determine or verify the eligibility of individuals to register
in the Medicare program to order and refer items and services to Medicare beneficiaries and to assist in the
administration of the Medicare program. This information will also be used to ensure that registered physician
and non-physician practitioners are not excluded from participation in the Medicare program. All information
on this form is required. Without this information, the ability to order ir refer 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.

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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.
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 0938-1135. The time required to complete this
information collection is estimated to be 30 minutes 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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