CMS-855S Medicare Durable Medical Equipment Supplier Enrollment A

Medicare Enrollment Application (Form 855S)

CMS-855S

Change of Enrollment Information

OMB: 0938-1056

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1056 can be found here:

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MEDICARE ENROLLMENT APPLICATION
Durable Medical Equipment, Prosthetics, Orthotics,
and Supplies (DMEPOS) Suppliers

CMS-855S

See page 1 for a list of the DMEPOS Supplier Standards. To enroll in
the Medicare program and be eligible to submit claims and receive
payments, every DMEPOS supplier applicant must meet and maintain
these enrollment standards.
See page 2 to determine if you are completing the correct application.
See page 3 for information on where to mail this Completed application.
See Section 12 for a list of supporting documentation to be submitted
with this application.

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

Form Approved
OMB No. 0938-1056

DMEPOS Supplier Standards for Medicare enrollment
This is an abbreviated list of the standards every Medicare DMEPOS supplier must meet in order to obtain and retain their
billing privileges. These standards, in their entirety, including the surety bond provisions, are listed in 42 C.F.R. 424.57(c) and
can be found at http://www.cms.gov/MedicareProviderSupEnroll/10_DMEPOSSupplierStandards.asp#TopOfPage.
14. A supplier must maintain and replace at no charge
or repair directly, or through a service contract with
another company, Medicare-covered items it has rented
to beneficiaries.
15. A supplier must accept returns of substandard (less than
full quality for the particular item) or unsuitable items
(inappropriate for the beneficiary at the time it was
fitted and rented or sold) from beneficiaries.
16. A supplier must disclose these supplier standards to
each beneficiary to whom it supplies a Medicarecovered item.
17. A supplier must disclose to the government any person
having ownership, financial, or control interest in the
supplier.
18. A supplier must not convey or reassign a supplier
number; i.e., the supplier may not sell or allow another
entity to use its Medicare billing number.
19. A supplier must have a complaint resolution protocol
established to address beneficiary complaints that relate
to these standards. A record of these complaints must be
maintained at the physical facility.
20. Complaint records must include: the name, address,
telephone number and health insurance claim number
of the beneficiary, a summary of the complaint, and any
actions taken to resolve it.
21. A supplier must agree to furnish CMS any information
required by the Medicare statute and implementing
regulations.
22. All suppliers must be accredited by a CMS-approved
accreditation organization in order to receive and
retain a supplier billing number. The accreditation must
indicate the specific products and services, for which the
supplier is accredited in order for the supplier to receive
payment of those specific products and services (except
for certain exempt pharmaceuticals).
23. All suppliers must notify their accreditation organization
when a new DMEPOS location is opened.
24. All supplier locations, whether owned or subcontracted,
must meet the DMEPOS quality standards and be
separately accredited in order to bill Medicare.
25. All suppliers must disclose upon enrollment all products
and services, including the addition of new product lines
for which they are seeking accreditation.
26. Must meet the surety bond requirements specified in
42 C.F.R. 424.57(d).
27. A supplier must obtain oxygen from a state- licensed
oxygen supplier.
28. A supplier must maintain ordering and referring
documentation consistent with provisions found in
42 C.F.R. 424.516(f).
29. DMEPOS suppliers are prohibited from sharing a
practice location with certain other Medicare providers
and suppliers.
30. DMEPOS suppliers must remain open to the public for a
minimum of 30 hours per week with certain exceptions.

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1. A supplier must be in compliance with all applicable
Federal and State licensure and regulatory requirements.
2. A supplier must provide complete and accurate
information on the DMEPOS supplier application.
Any changes to this information must be reported
to the National Supplier Clearinghouse Medicare
Administrative Contractor within 30 days.
3. An authorized individual (one whose signature is
binding) must sign the application for billing privileges.
4. A supplier must fill orders from its own inventory, or
must contract with other companies for the purchase
of items necessary to fill the order. A supplier may not
contract with any entity that is currently excluded from
the Medicare program, any State health care programs,
or from any other Federal procurement or nonprocurement programs.
5. A supplier must advise beneficiaries that they may rent
or purchase inexpensive or routinely purchased durable
medical equipment, and of the purchase option for
capped rental equipment.
6. A supplier must notify beneficiaries of warranty
coverage and honor all warranties under applicable
State law, and repair or replace free of charge Medicare
covered items that are under warranty.
7. A supplier must maintain a physical facility on an
appropriate site. This standard requires that the location
is accessible to the public and staffed during posted
hours of business. The location must be at least 200
square feet and contain space for storing records. The
supplier location must be accessible to beneficiaries
during reasonable business hours, and must maintain a
visible sign and posted hours of operation.
8. A supplier must permit CMS, or its agents to conduct
on-site inspections to ascertain the supplier’s compliance
with these standards.
9. A supplier must maintain a primary business telephone
listed under the name of the business in a local directory
or a toll free number available through directory
assistance. The exclusive use of a beeper, answering
machine, answering service or cell phone during posted
business hours is prohibited.
10. A supplier must have comprehensive liability insurance
in the amount of at least $300,000 that covers both
the supplier’s place of business and all customers and
employees of the supplier. If the supplier manufactures
its own items, this insurance must also cover product
liability and completed operations.
11. A supplier must agree not to initiate telephone contact
with beneficiaries, with a few exceptions allowed. This
standard prohibits suppliers from contacting a Medicare
beneficiary based on a physician’s oral order unless an
exception applies.
12. A supplier is responsible for delivery and must instruct
beneficiaries on use of Medicare covered items, and
maintain proof of delivery.
13. A supplier must answer questions and respond to
complaints of beneficiaries, and maintain documentation
of such contacts.
CMS-855S (09/12)

who should complete and submit this application
The following types of DMEPOS suppliers must complete this application
• Ambulatory Surgical Center
• Nursing Facility (other)
• Ocularist
• Department Store
• Grocery Store
• Occupational Therapist
• Home Health Agency
• Optician
• Hospital
• Orthotics Personnel
• Indian Health Service
• Oxygen and/or Oxygen
Related Equipment Supplier
• Intermediate Care
• Pedorthic Personnel
Nursing Facility
• Medical Supply Company
• Pharmacy

to initiate the enrollment process:
• Physical Therapist
• Physician, including Dentist
and Optometrist
• Prosthetics Personnel
• Prosthetic/Orthotic Personnel
• Rehabilitation Agency
• Skilled Nursing Facility
• Sleep Laboratory/Medicine
• Sports Medicine

If your DMEPOS supplier type is not listed, contact the National Supplier Clearinghouse Medicare
Administrative Contractor (NSC MAC) before you submit your application.

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Complete this application if you plan to bill Medicare for DMEPOS and you are:
• Enrolling in Medicare for the first time as a DMEPOS supplier.
• Currently enrolled in Medicare as a DMEPOS supplier and need to report changes to your current business,
(e.g., you are adding, deleting, or changing existing information under this Medicare supplier billing
number). Changes must be reported within 30 days of the change.
• Currently enrolled in Medicare as a DMEPOS supplier and need to enroll a new business location using the
same tax identification number already enrolled with the NSC MAC.
• Currently enrolled in Medicare as a DMEPOS supplier and need to enroll a new business location using a
tax identification number not currently enrolled with the NSC MAC.
• Currently enrolled in Medicare as a DMEPOS supplier and received notice to revalidate your enrollment.
• Reactivating your Medicare DMEPOS supplier billing number.
• Voluntarily terminating your Medicare DMEPOS supplier billing number.

Suppliers of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) can apply for
enrollment 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
• submitting the paper CMS-855S enrollment application. When submitting the paper CMS-855S application,
be sure you are using the most current version.
For additional information regarding the Medicare enrollment process, including Internet-based PECOS and to
get the current version of the CMS-855S, go to http://www.cms.gov/MedicareProviderSupEnroll.

billing number and national provider identifier information

The Medicare Identification Number, often referred to as a Medicare supplier number or Medicare billing
number is a generic term for any number other than the National Provider Identifier (NPI) that is used by a
DMEPOS supplier to bill the Medicare program.
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). To become a
Medicare DMEPOS supplier, you must obtain an NPI and furnish it on this application prior to enrolling in
Medicare or when submitting a change to your existing Medicare enrollment 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.gov/NationalProvIdentStand.
Note: The Legal Business Name (LBN) and Tax Identification Number (TIN) that you furnish in Section 1B of
this application must be the same LBN and TIN you used to obtain your National Provider Identifier (NPI). Your
Legal Business Name, Tax Identification Number and National Provider Identifier must match exactly in both
the Medicare Provider Enrollment Chain and Ownership System (PECOS) and the National Plan and Provider
Enumeration System (NPPES).

INSTRUCTIONS FOR COMPLETING THIS APPLICATION
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Type or print all information so that it is legible. Do not use pencil. Blue ink preferred.
When necessary to report additional information, copy and complete the applicable section as needed.
Attach all supporting documentation.
Keep a copy of your completed Medicare enrollment package for your own records.

CMS-855S (09/12)

Tips to AVOID DELAYS IN YOUR ENROLLMENT
To
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avoid delays in the initial enrollment process, you should:
Complete all required sections as shown in Section 1;
Complete Section 9 for all delegated and authorized officials reported in Sections 14 and 15;
List at least one managing employee for each location;
Enter your NPI in the applicable sections;
Include the Electronic Funds Transfer (EFT) Agreement with your enrollment application;
Respond timely to development/information requests; and
Be sure the Legal Business Name shown in Section 1B matches the name on your tax documents.

Additional information and reasons for enrollment processing delays can be found on the NSC MAC website at
www.palmettogba.com/nsc.

process for Obtaining medicare approval

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The usual process for becoming a Medicare DMEPOS supplier is as follows:
1. The supplier obtains the required National Provider Identification Number (NPI), surety bond and/or
accreditation PRIOR to completing and submitting this application to the NSC MAC.
2. The supplier completes and submits an enrollment application (CMS-855S) and all supporting
documentation to the NSC MAC.
3. The NSC MAC reviews the application and conducts a site visit to verify compliance with the supplier
standards found at 42 C.F.R. 424.57, 424.58, and 42 C.F.R. 424.500–565.
4. After completing its review, the NSC MAC notifies the applicant in writing about its enrollment decision.

ADDITIONAL INFORMATION

The NSC MAC may request, at any time during the enrollment process, documentation to support or validate
information reported on the application. You are responsible for providing this documentation within 30 days
of the request.

The information you provide on this form will only be disclosed according to the routine uses found in the
Privacy Act Statement on the last page of this application. It is considered to be protected under 5 U.S.C.
Section 552(b)(4) and/or (b)(6), respectively. For more information, read the Privacy Act Statement.

Acronyms Commonly Used in this application
NPI: National Provider Identifier

DME MAC: Durable Medical Equipment Medicare
Administrative Contractor

NPPES: National Plan and Provider
Enumeration System

DMEPOS: Durable Medical Equipment, Prosthetics,
Orthotics and Supplies

NSC MAC: National Supplier Clearinghouse Medicare
Administrative Contractor

EFT: Electronic Funds Transfer
IRS: Internal Revenue Service

PECOS: Provider Enrollment Chain and Ownership
System

LBN: Legal Business Name

SSN: Social Security Number

LLC: Limited Liability Corporation

TIN: Tax Identification Number

C.F.R: Code of Federal Regulation

U.S.C.: United States Code

where to MAIL Your APPLICATION
The NSC MAC is responsible for processing your enrollment application. Mail this application to:
National Supplier Clearinghouse
Post Office Box 100142
Columbia, SC 29202-3142
Customer Service: 1-866-238-9652
Web: https://www.palmettogba.com/nsc
CMS-855S (09/12)

Overnight Mailing Address:
National Supplier Clearinghouse
Palmetto GBA* AG-495
2300 Springdale Drive, Bldg. 1
Camden, SC 29020
3

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 in Section 1B.

NEW ENROLLEES and those reporting a new tax id number
You are considered a new enrollee if you are:
• Enrolling in the Medicare program as a DMEPOS supplier for the first time under the tax identification
number reported in Section 1B.
• Currently enrolled in the Medicare program as a DMEPOS supplier but have a new tax identification
number. If you are reporting a change to your tax identification number, you must complete a new
CMS-855S enrollment application in it’s entirety.
• A currently enrolled DMEPOS supplier under new ownership with a different tax identification number.
Note: New owners of existing DMEPOS suppliers must submit a dated bill of sale with the effective date
of the new ownership.

currently enrolled MEDICARE DMEPOS SUPPLIERS

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Adding a New Location
If you are currently enrolled as a Medicare DMEPOS supplier and are applying to enroll a new business
location using a tax identification number that is already enrolled with the NSC MAC, you will need to
complete only the required sections listed in Section 1C of this application for the new location.
Change of Information Other Than Adding a New Location
If you are adding, deleting, or changing information under your current Medicare supplier billing number,
including a change of ownership that does not change the current tax identification number. Any change to
your existing enrollment data must be reported within 30 days of the effective date of the change.
Reactivation
If your Medicare DMEPOS supplier billing number was deactivated, you will be required to submit an updated
CMS-855S. You must also meet all current requirements for your supplier type to reactivate your supplier
billing number.

Revalidation
If you have been contacted by the NSC MAC to revalidate your Medicare enrollment you will be required to
submit an updated enrollment application. Do not submit an application for revalidation until you have been
contacted by the NSC MAC.

Voluntary Termination
If you will no longer provide DMEPOS items or services to Medicare beneficiaries you should voluntarily
terminate your enrollment in the Medicare program as a DMEPOS supplier.
Note: Enrollment applications submitted for “New Enrollees” MUST be signed by an Authorized Official,
otherwise they will be returned unprocessed.

CMS-855S (09/12)

SECTION 1: basic information (Continued)
A. Business Location

Provide the two-letter State Code (e.g., TX for Texas) where this business is physically located.

B. Business Identification

DMEPOS suppliers must furnish their National Provider Identifier (NPI), Tax Identification Number (TIN), and
Supplier Billing Number (if issued) below.
Note: Each practice location must have it’s own NPI, unless enrolling as a sole proprietor/proprietorship with
multiple locations. See Section 2C.
Legal Business Name (LBN)
National Provider Identifier (NPI)

Tax Identification Number (TIN)

Supplier Billing Number (if issued)

C. Reason for Submitting This Application

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Check one box and complete the Sections of this application as indicated.
Complete all sections

You are adding a new business location using a tax identification number
currently enrolled with the NSC MAC.

1–4, 6–7, 9 (for managing
employee only), 11, and
either 14 or 15

You are adding a new business location using a tax identification number
NOT currently enrolled with the NSC MAC.

Complete all sections

You are reactivating your Medicare Supplier Billing Number.

Complete all sections

You are revalidating your Medicare enrollment.

Complete all sections

You are a new enrollee in Medicare or are enrolling a new location with a tax
identification number not previously enrolled with the NSC MAC.

You are voluntarily terminating your Medicare enrollment.

Effective date of termination: ____________________

1, 2A, 4B, 4D, 11, and
either 14 or 15

You are changing your Medicare enrollment information other than your tax
identification number.

Go to Section 1D

You are changing your Tax Identification Number.

Complete all sections

CMS-855S (09/12)

SECTION 1: basic information (Continued)
D. What information is changing?

Check all that apply and complete the required sections.
Please note: When reporting ANY change of information, Sections 1B, 7 and either 14 or 15 MUST always
be completed. Otherwise, only complete the information that is changing within the required Section or
Sub-Section.

Check ALL THAT APPLY

REQUIRED SECTIONS
1, 2A, 2B, 5, 7, 11 (optional), and
either 14 or 15

Current Business Location
Supplier Type
(submit licensure if applicable)
Products and Services
(submit accreditation if applicable)

1, 3, 7, 11 (optional), and either
14 or 15
1, 3, 7, 11 (optional), and either
14 or 15

Address Information
1099 Mailing Address
Correspondence Mailing Address
Revalidation Mailing Address
Remittance/Special Payment Mailing Address
Record Storage Address

1, 4 as applicable for the address
that is being changed, 7, 11
(optional), and either 14 or 15.

Comprehensive Liability Insurance Information

1, 5, 7, 11 (optional), and either
14 or 15

Surety Bond Information

1, 6, 7, 11 (optional), and either
14 or 15

Final Adverse Legal Actions

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Accreditation Information

Ownership and/or Managing Control Information
(Organizations and/or Individuals)

1, 7, 11 (optional), and either
14 or 15
1, 7, 8 and/or 9, 11 (optional),
and either 14 or 15

Billing Agency Information

1, 7, 10, 11 (optional), and either
14 or 15

Delegated Official

1, 7, 9, 11 (optional), 14 and 15

Authorized Official

1, 7, 9, 11 (optional), 15

Any other information not specified above

1, 7, 11 (optional), and either 14
or 15 and the applicable section
or sub-section that is changing.

CMS-855S (09/12)

SECTION 2: Identifying information
A. BUSINESS LOCATION INFORMATION
This section captures information regarding your business location.
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A separate application must be submitted for each physical business location that you intend to bill
Medicare for items sold or services rendered to Medicare beneficiaries from that location. Locations that
serve only as warehouses or repair facilities should not be reported.
The address must be a specific street address as recorded by the United States Postal Service. Do not
furnish a P.O. Box. If you are located in a hospital and/or other health care facility and you provide services
to patients at that facility, furnish the name and address of the hospital or facility.
A change to the business location address requires submission of professional and business licenses for the
new address, and proof of insurance covering the new address.

If you are reporting a change in this section, please check the box and furnish the effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
Business Location Name/Doing Business As Name (Not your billing agent, staffing company, or managing organization)

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Business Location Address Line 1 (Street Name and Number)
Business Location Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Telephone Number

ZIP Code + 4

Fax Number (if applicable)

E-mail Address (if applicable)

Date this Business Started at this Location (mm/dd/yyyy) Date this Business Terminated at this Location (if applicable) (mm/dd/yyyy)

B. Hours of Operation

List your posted hours of operation as displayed at the business location in Section 2A above.
If you are reporting a change in this section, please check the box and furnish the effective date below.

Change Effective Date (mm/dd/yyyy): _______________________________
You must list all hours of each day you are open or available to the public, including “By Appointment” times.
Check and/or complete all boxes and/or sections for each day as appropriate.
Open 24/7 (Open 24 hours a day, 7 days a week)
By Appointment Only (no fixed days or hours), or
By Appointment Only (days and times indicated below)
Day of Week

By Appointment
Only

Hours
Open

Closed
All Day

Sunday

Yes

Monday

Yes

Tuesday

Yes

Wednesday

Yes

Thursday

Yes

Friday

Yes

Saturday

Yes

Please indicate A.M. or P.M next to each time.
CMS-855S (09/12)

Total Hours Available
to Public for Day

Total Hours Available to
Public for Week
7

SECTION 2: Identifying information (Continued)
C. Business Structure Information
Identify the type of business structure for this supplier (Check one):
Not Publically Traded Corporation (regardless of whether supplier is “for-profit” or “non-profit”)
Publically Traded Corporation (regardless of whether supplier is “for-profit” or “non-profit”)
Limited Liability Company (LLC)
Partnership (“general” or “limited”)
Sole Proprietor/Sole Proprietorship
Government Owned
Other (Specify) ________________________________

D. Internal Revenue Service Registration Information
Identify how your business is registered with the IRS.
If you check Non-Profit submit a copy of your IRS 501(c)(3).
If you check Disregarded Entity submit a copy of your IRS Form 8832.
Note: If your business is a Federal and/or State government supplier indicate “Non-Profit” below.
Non-Profit

Disregarded Entity

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Proprietary

E. States where items provided

Select all State(s)/Territory(ies) where you provide items or services to Medicare beneficiaries from the business
location in Section 2A. For each State/Territory selected, submit all required licenses for the products and
services being provided.

Connecticut
Delaware
District of Columbia

Maine
Maryland
Massachusetts

New Hampshire
New Jersey
New York

Michigan
Minnesota
Ohio

Wisconsin

Jurisdiction A:
All States in Jurisdiction A

Pennsylvania
Rhode Island
Vermont

Illinois
Indiana
Kentucky

Jurisdiction B:
All States in Jurisdiction B

Jurisdiction C:
All States and Territories in Jurisdiction C
Alabama
Arkansas
Colorado
Florida
Georgia

Louisiana
Mississippi
New Mexico
North Carolina
Oklahoma

Puerto Rico
South Carolina
Tennessee
Texas
Virgin Islands

Virginia
West Virginia

Nebraska
Nevada
North Dakota
Oregon
South Dakota

Utah
Washington
Wyoming
Northern Mariana Islands
American Samoa

Jurisdiction D:
All States and Territories in Jurisdiction D
Alaska
Arizona
California
Guam
Hawaii

CMS-855S (09/12)

Idaho
Iowa
Kansas
Missouri
Montana

SECTION 3: Products/accreditation information
A. Type of Supplier
The supplier must meet all Medicare requirements for the DMEPOS supplier type checked. Any specialty
personnel, including, but not limited to, Respiratory Therapists, and Orthotics/Prosthetics personnel, must
have current licensure as applicable to the specialty supplier type checked as well as for products and services
checked in Sections 3C and 3D.
Check all that apply:
Nursing Facility (other)
Ocularist
Occupational Therapist
Optician
Orthotics Personnel
Oxygen and/or Oxygen Related
Equipment Supplier
Pedorthic Personnel
Pharmacy
Physical Therapist
Physician
Physician/Dentist
Physician/Optometrist
Prosthetics Personnel
Prosthetic and Orthotic Personnel
Rehabilitation Agency
Skilled Nursing Facility
Sleep Laboratory/Medicine
Sports Medicine
Other__________________________________

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Ambulatory Surgical Center
Department Store
Grocery Store
Home Health Agency
Hospital
Indian Health Service
Intermediate Care Nursing Facility
Medical Supply Company
Medical Supply Company
with Orthotics Personnel
Medical Supply Company
with Pedorthic Personnel
Medical Supply Company
with Prosthetics Personnel
Medical Supply Company
with Prosthetic and Orthotic Personnel
Medical Supply Company
with Registered Pharmacist
Medical Supply Company
with Respiratory Therapist

B. Accreditation Information

Note: If more than one accreditation needs to be reported, copy and complete this section for each.

Check one of the following and furnish any additional information as requested:
The enrolling supplier business location in Section 2A is accredited.
The enrolling supplier business location in Section 2A is exempt from accreditation requirements.
To determine if you qualify for exemption, go to https://www.palmettogba.com/NSC.
Name of Accrediting Organization
Effective Date of Current Accreditation (mm/dd/yyyy)

Expiration Date of Current Accreditation (mm/dd/yyyy)

C. Non-Accredited Products
Check all that apply. These products do not require accreditation.
Epoetin
Immunosuppressive Drugs
Infusion Drugs
Nebulizer Drugs
Oral Anticancer Drugs

Oral Antiemetic Drugs (Replacement for Intravenous Antiemetics)

Note: Check here if the supplier provides one or more of the products shown above but does not furnish
any of the products and/or services listed in Section 3D. If checked, skip Section 3D and continue to
Section 4.
CMS-855S (09/12)

SECTION 3: Products/accreditation information (Continued)
D. Products and Services Furnished by this Supplier
Check all that apply and submit all applicable licenses and/or certifications.
If you are unsure of the licensure and/or certification and/or accreditation requirements for your product(s)
or services(s), check with your State. The NSC MAC website at https://www.palmettogba.com/nsc may offer
guidance. Failure to attach applicable licensure and/or certification could result in denial or revocation of your
Medicare billing privileges and/or overpayment collection.
Orthoses: Off-the-Shelf
Osteogenesis Stimulators
Ostomy Supplies
Oxygen Equipment and/or Supplies
Parenteral Nutrients
Parenteral Equipment and/or Supplies
Patient Lifts
Penile Pumps
Pneumatic Compression Devices and/or Supplies
Power Operated Vehicles (Scooters)
Prosthetic Lenses: Conventional Contact Lenses
Prosthetic Lenses: Conventional Eyeglasses
Prosthetic Lenses: Prosthetic Cataract Lenses
Respiratory Assist Devices
Respiratory Suction Pumps
Seat Lift Mechanisms
Somatic Prostheses
Speech Generating Devices
Support Surfaces: Pressure Reducing Beds/
Mattresses/Overlays/Pads
Surgical Dressings
Tracheostomy Supplies
Traction Equipment
Transcutaneous Electrical Nerve Stimulators
(TENS) and/or Supplies
Ultraviolet Light Devices and/or Supplies
Urological Supplies
Ventilators Accessories and/or Supplies
Voice Prosthetics
Walkers
Wheelchair Seating/Cushions
Wheelchairs—Complex Rehabilitative
Manual Wheelchairs
Wheelchairs—Complex Rehabilitative
Manual Wheelchair Related Accessories
Wheelchairs—Complex Rehabilitative
Power Wheelchairs
Wheelchairs—Complex Rehabilitative
Power Wheelchair Related Accessories
Wheelchairs—Standard Manual
Wheelchairs—Standard Manual
Related Accessories
Wheelchairs—Standard Power
Wheelchairs—Standard Power
Related Accessories

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Automatic External Defibrillators (AEDs)
and/or Supplies
Blood Glucose Monitors and/or Supplies (mail order)
Blood Glucose Monitors and/or Supplies
(non-mail order)
Breast Prostheses and/or Accessories
Canes and/or Crutches
Cochlear Implants
Commodes/Urinals/Bedpans
Continuous Passive Motion (CPM) Devices
Continuous Positive Airway Pressure (CPAP) Devices
and/or Supplies
Contracture Treatment Devices: Dynamic Splint
Diabetic Shoes/Inserts
Diabetic Shoes/Inserts—Custom
Enteral Nutrients
Enteral Equipment and/or Supplies
External Infusion Pumps and/or Supplies
Facial Prostheses
Gastric Suction Pumps
Heat & Cold Applications
Hemodialysis Equipment and/or Supplies
High Frequency Chest Wall Oscillation (HFCWO)
Devices and/or Supplies
Home Dialysis Equipment and/or Supplies
Hospital Beds—Electric
Hospital Beds—Manual
Implanted Infusion Pumps and/or Supplies
Infrared Heating Pad Systems and/or Supplies
Insulin Infusion Pumps and/or Supplies
Intermittent Positive Pressure Breathing (IPPB)
Devices
Intrapulmonary Percussive Ventilation Devices
Invasive Mechanical Ventilation Devices
Limb Prostheses
Mechanical In-Exsufflation Devices
Nebulizer Equipment and/or Supplies
Negative Pressure Wound Therapy Pumps
and/or Supplies
Neuromuscular Electrical Stimulators (NMES)
and/or Supplies
Neurostimulators and/or Supplies
Ocular Prostheses
Orthoses: Custom Fabricated
Orthoses: Prefabricated (non-custom fabricated)
CMS-855S (09/12)

SECTION 4: Important address information
DO NOT PROVIDE any INFORMATION about your billing agent anywhere in section 4. see section
10 to report all Billing Agent Information.

A. 1099 Mailing Address
1. Organizational Suppliers (e.g., Corporations, Partnerships, LLCs, Sub-Chapter S)
If you are an organizational supplier, furnish the supplier’s legal business name (as reported to the IRS) and
TIN. Furnish 1099 mailing address information where indicated. A copy of the IRS CP-575 or other document
issued by the IRS showing the TIN and LBN for this business MUST be submitted.
If you are reporting a change in this section, please check the box and furnish the effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
Organizational Suppliers: 1099 Mailing Address
Legal Business Name as Reported to the IRS
Tax Identification Number

Prior Tax Identification Number (if applicable)

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1099 Mailing Address Line 1 (P.O. Box or Street Name and Number)
1099 Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
1099 Mailing Address City/Town

2. Sole Proprietors

1099 Mailing Address State

1099 Mailing Address ZIP Code + 4

If you are a sole proprietor (the only owner of a business that is not incorporated), list your Social Security
Number (SSN) and the full legal name associated with your SSN as reported to the IRS in the appropriate fields.
If you want your Medicare payments reported under your Employer Identification Number (EIN) furnish it in
the appropriate space below. Furnish 1099 mailing address information where indicated.

NOTE: Sole Proprietors: If you furnish an EIN, payment will be made to your EIN. If you do not furnish an EIN,
payment will be made to your SSN. You can not use both an SSN and EIN. You can only use one number to bill
Medicare. If furnishing an EIN, a copy of the IRS CP-575 or other document issued by the IRS showing the EIN
and legal name for this business MUST be submitted.
If you are reporting a change in this section, please check the box and furnish the effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
Sole Proprietors: 1099 Mailing Address
Full Legal Name Associated with this Social Security Number
Social Security Number

Employer Identification Number

Prior Employer Identification Number (if applicable)

1099 Mailing Address Line 1 (P.O. Box or Street Name and Number)
1099 Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
1099 Mailing Address City/Town

CMS-855S (09/12)

1099 Mailing Address State

1099 Mailing Address ZIP Code + 4

SECTION 4: Important address information (Continued)
B. correspondence mailing address
This is the address where correspondence will be sent to you by the NSC MAC and/or the DME MAC.
Check

here if you want all Correspondence mailed to the address furnished below.
here if you want all Correspondence mailed to your Business Location Address in Section 2A and
skip this section.
If you are reporting a change in this section, please check the box and furnish the effective date below.
Check

Change Effective Date (mm/dd/yyyy): _______________________________
Business Location Name (Not your billing agent, staffing company, or managing organization)
Attention
Mailing Address Line 1 (P.O. Box or Street Name and Number)
Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

Telephone Number (if applicable)

ZIP Code + 4

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State
Fax Number (if applicable)

E-mail Address (if applicable)

c. Revalidation request package mailing address

This is the address where the NSC MAC will send your enrollment revalidation request package.
Check

here if your Revalidation Request Package should be mailed to the address furnished below.
here if your Revalidation Request Package should be mailed to your Business Location Address in
Section 2A and skip this section.
Check here if your Revalidation Request Package should be mailed to your Correspondence Address in Section
4B and skip this section.

Check

If you are reporting a change in this section, please check the box and furnish the effective date below.

Change Effective Date (mm/dd/yyyy): _______________________________
Business Location Name
Attention

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

CMS-855S (09/12)

State

Fax Number (if applicable)

ZIP Code + 4
E-mail Address (if applicable)

SECTION 4: Important address information (Continued)
D. Remittance Notices/Special Payments mailing address
Medicare will issue all routine payments via electronic funds transfer (EFT). Since payment will be made
by EFT, the “special payments” address below should indicate where all other payment information (e.g.,
remittance notices and non-routine “special payments”) should be sent.
Check

here if your Remittance Notices/Special Payments should be mailed to the address furnished below.
here if your Remittance Notices/Special Payments should be mailed to your Business Location Address in
Section 2A and skip this section.
Check here if your Remittance Notices/Special Payments should be mailed to your Correspondence Address in
Section 4B and skip this section.
Check

NOTE: If you are a new enrollee or are adding a new business location, you must submit an EFT
Authorization Agreement (CMS-588) with this application.
If you need to make changes to your current EFT Authorization Agreement (CMS-588), contact the DME MAC.
If you are reporting a change in this section, please check the box and furnish the effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
NOTE: Payments will be made in the supplier’s “legal business name” as shown in Section 1B.

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“Special Payments” Address Line 1 (PO Box or Street Name and Number)
“Special Payments” Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

ZIP Code + 4

E. Medicare Beneficiary Medical Records storage address

If the Medicare beneficiaries’ (current and former) medical records are stored at a location other than the
location shown in Section 2A in accordance with 42 C.F.R. 424.57 (c)(7)(E), complete this section with the
name and address of the storage location. This includes the records for both current and former Medicare
beneficiaries.

Post office boxes and drop boxes are not acceptable as a physical address where Medicare beneficiaries’
records are maintained. The records must be the supplier’s records, not the records of another supplier. If all
records are stored at the business location reported in Section 2A, please indicate below.
Records are stored at the business location reported in Section 2A.
If you are adding or deleting a storage location, please check the box and furnish the effective date below.
Add

Delete

Effective Date (mm/dd/yyyy): _______________________________

1. Paper Storage
Name of Storage Facility
Storage Facility Address Line 1 (Street Name and Number)
Storage Facility Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

2. Electronic Storage
Do you store your patient medical records electronically?

ZIP Code + 4

Yes

If yes, identify where/how these records are stored below. This can be a website, URL, in-house software
program, online service,vendor, etc. This must be a site that can be accessed by the NSC MAC if necessary.
Site where electronic records stored

CMS-855S (09/12)

SECTION 5: comprehensive liability insurance Information
Consistent with DMEPOS supplier standard #10, all DMEPOS suppliers must have comprehensive liability
insurance in the amount of at least $300,000 per occurrence and remain in force at all times. The NSC MAC,
with full mailing address as shown on page 3, must be listed on the policy as a Certificate Holder. You must
submit a copy of the liability insurance policy or evidence of self-insurance with this application. Failure to
maintain the required insurance at all times will result in revocation of the Medicare supplier billing number,
retroactive to the date the insurance lapsed.
Malpractice Insurance is not the same as Comprehensive Liability Insurance and does not meet compliance for
this requirement.
If you are changing insurance information, check the applicable box and furnish the effective date.
Change Effective Date (mm/dd/yyyy): _______________________________
Name of Insurance Company
Insurance Policy Number

Date Policy Issued (mm/dd/yyyy)

Insurance Agent’s First Name

Middle Initial

Agent’s Telephone Number

Agent’s Fax Number (if applicable)

Last Name

Jr., Sr., M.D., etc.
Agent’s E-mail Address (if applicable)

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Underwriter’s Company Name

Expiration Date of Policy (mm/dd/yyyy)

Underwriter’s Telephone Number

Underwriter’s Fax Number (if applicable)

Underwriter’s E-mail Address (if applicable)

SECTION 6: SURETY BOND INFORMATION

Check

This section is to be completed by all DMEPOS suppliers as required by regulation 42 C.F.R. § 424.57(d) to
obtain a surety bond. Furnish all requested information about the surety bond company, and the surety bond.
A copy of the original surety bond, signed by the Delegated or Authorized Official, must be submitted with
this application.
here if this supplier is not required to obtain a surety bond and skip to Section 7.

A. Name and Address of Surety Bond Company
If you are changing surety bond information, check the applicable box and furnish the effective date.
Change Effective Date (mm/dd/yyyy): _______________________________
Legal Business Name of Surety Bond Company as Reported to the IRS

Tax Identification Number

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

State
Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

B. Surety Bond Information
Change Effective Date (mm/dd/yyyy): _______________________________
Amount of Surety Bond

Surety Bond Number

$
Effective Date of Surety Bond (mm/dd/yyyy)
CMS-855S (09/12)

If reporting a new bond, give cancellation date of the current bond (mm/dd/yyyy)
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SECTION 7: 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.

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A. Convictions
1. The DMEPOS supplier was, within the last 10 years preceding enrollment or revalidation of enrollment,
convicted of a Federal or State felony offense. 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 felony 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
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 in this section, please check the box and furnish the effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
1. Have you or your organization, under any current or former name or business identity, ever had a final
adverse legal action listed above imposed against you/it?
YES–Continue Below

NO–Skip to Section 8

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).
CMS-855S (09/12)

SECTION 8: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION

(ORGANIZATIONS)
NOTE: Only report organizations in this section. Individuals must be reported in Section 9.
Complete this section with information about all organizations that have 5 percent or more (direct or indirect)
ownership interest of, any partnership interest in, and/or managing control of, the supplier identified in
Section 2A, as well as any information on final adverse legal actions that have been imposed against that
organization. For more information on “direct” and “indirect” owners and examples of organizations that
must be reported in this section, go to: https://www.cms.gov/MedicareProviderSupEnroll. If there is more
than one organization with ownership interest or managing control, copy and complete this section for each.

Ownership interest (organizations)
All
•
•
•

organizations that have any of the following must be reported:
5 percent or more ownership of the DMEPOS supplier,
Managing control of the DMEPOS supplier, or
A partnership interest in the DMEPOS supplier, regardless of the percentage of ownership the partner has.

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Owning/Managing organizations are generally one of the following types:
• Corporations (including non-profit corporations)
• Partnerships and Limited Partnerships (as indicated above)
• Limited Liability Companies
• Charitable and/or Religious organizations, or
• Governmental and/or Tribal organizations

MANAGING CONTROL (ORGANIZATIONS)

Any organization that exercises operational or managerial control over the DMEPOS supplier, or conducts
the day-to-day operations of the DMEPOS supplier, is a managing organization and must be reported. The
organization need not have an ownership interest in the DMEPOS supplier in order to qualify as a managing
organization. For instance, it could be a management services organization under contract with the DMEPOS
supplier to furnish management services for this business location.

SPECIAL TYPES OF ORGANIZATIONS

Governmental/Tribal Organizations:
If a Federal, State, county, city or other level of government, or an Indian tribe, will be legally and financially
responsible for Medicare payments received (including any potential overpayments), the name of that
government or Indian tribe must be reported as an owner. The DMEPOS supplier must submit a letter on
the letterhead of the responsible government (e.g., government agency) or tribal organization that attests
that the government or tribal organization will be legally and financially responsible in the event that there
is any outstanding debt owed to CMS. This letter must be signed by an appointed or elected official of the
government or tribal organization who has the authority to legally and financially bind the government or
tribal organization to the laws, regulations, and program instructions of Medicare.
Indian Health Service Facilities:
Special rules concerning insurance and licenses apply. Contact the NSC MAC concerning these rules.
Non-Profit, Charitable and Religious Organizations:
Many non-profit organizations are charitable or religious in nature, and are operated and/or managed by
a Board of Trustees or other governing body. The actual name of the Board of Trustees or other governing
body must be reported in this section. While the organization must be reported in Section 8, individual board
members must be reported in Section 9. Each non-profit organization must submit a copy of the IRS document
501(c)(3) verifying its non-profit status.

CMS-855S (09/12)

SECTION 8: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION

(ORGANIZATIONS) (Continued)
A. ORGANIZATION IDENTIFICATION INFORMATION (OWNERSHIP AND/OR MANAGING CONTROL)
Check here if this section is not applicable for the supplier reported in Section 2A, and skip to Section 9.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Change

Add

Delete Effective Date (mm/dd/yyyy): _______________________________

1. Complete all identifying information below.
Legal Business Name as Reported to the Internal Revenue Service
“Doing Business As” Name (if applicable)
Business Address Line 1 (Street Name and Number)
Business Address Line 2 (Suite, Room, Apt. #, etc.)
State

ZIP Code + 4

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City/Town
Tax Identification Number (Required)
Telephone Number

NPI (if issued)

Medicare Identification Number(s) (if issued)

Fax Number (if applicable)

E-mail Address (if applicable)

2. What is the above organization’s relationship with the supplier in Section 2A? (Check all that apply.)
5 Percent or More Ownership Interest
Partner
Managing Control

3. What is the effective date this organization acquired and/or ended ownership or a partnership of the
supplier identified in Section 2A of this application? Furnish both dates if applicable.
Acquired Effective Date (mm/dd/yyyy): _______________________________
Ended Effective Date (mm/dd/yyyy): _______________________________

4. What is the effective date this organization acquired and/or ended managing control of the supplier
identified in Section 2A of this application? Furnish both dates if applicable.
Acquired Effective Date (mm/dd/yyyy): _______________________________
Ended Effective Date (mm/dd/yyyy): _______________________________

B. FINAL ADVERSE LEGAL ACTION HISTORY
Complete this section for each organization reported in Section 8A.
If you are reporting a change in this section, please check the box and list effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
1. Has this organization in Section 8A above, under any current or former name or business identity, ever had
a final adverse legal action listed in Section 7 of this application imposed against it?
YES–Continue Below

NO–Skip to Section 9

Date

Taken By

Resolution

Attach a copy of the final legal adverse action documentation(s) and resolution(s).
CMS-855S (09/12)

SECTION 9: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION

(INDIVIDUALS)
NOTE: Only report individuals in this section. Organizations must be reported in Section 8.
Complete this section with information about all individuals that have 5 percent or more (direct or indirect)
ownership interest of, any partnership interest in, and/or managing control of, the supplier identified in
Section 2A, as well as any information on final adverse legal actions that have been imposed against that
individual. For more information on “direct” and “indirect” owners and examples of individuals that must be
reported in this section, go to: https://www.cms.gov/MedicareProviderSupEnroll. If there is more than one
individual with ownership interest or managing control, copy and complete this section for each.
The supplier MUST have at least ONE owner and ONE managing employee.
NOTE: An owner may also be the managing employee.

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The following individuals must be reported in Section 9A:
• All persons who have a 5 percent or greater ownership (direct or indirect) interest in the
DMEPOS supplier.
• If (and only if) the DMEPOS supplier is a corporation (whether for-profit or non-profit), all officers and
directors of the DMEPOS supplier.
• All managing employees of the DMEPOS supplier.
• All individuals with a partnership interest in the DMEPOS supplier, regardless of the percentage of
ownership the partner has; and
• Authorized and delegated officials.
Example: A supplier is 100 percent owned by Company C, which itself is 100 percent owned by Individual
D. Assume that Company C is reported in Section 8 as an owner of the supplier. Assume further that
Individual D, as an indirect owner of the supplier, is reported in Section 9A1. Based on this example, the
suppler would check the “5 Percent or Greater Direct/Indirect Owner” box in Section 9A2.

NOTE: All partners within a partnership must be reported in this application. This applies to both “General”
and “Limited” partnerships. For instance, if a limited partnership has several limited partners and each
of them only has a 1 percent interest in the DMEPOS supplier, each limited partner must be reported in
this application, even though each owns less than 5 percent. The 5 percent threshold primarily applies to
corporations and other organizations that are not partnerships.

For purposes of this application, the terms “officer,” “director,” and “managing employee” are defined
as follows:
• The term “Officer” is defined as any person whose position is listed as being that of an officer in the
DMEPOS supplier’s “articles of incorporation” or “corporate bylaws,” OR anyone who is appointed by the
board of directors as an officer in accordance with the DMEPOS supplier’s corporate bylaws.
• The term “Director” is defined as a member of the DMEPOS supplier’s “board of directors.” It does not
necessarily include a person who may have the word “Director” in his/her job title (e.g., Departmental
Director, Director of Operations).
• The term “Managing Employee” means a general manager, business manager, administrator, director,
or other individual who exercises operational or managerial control over, or who directly or indirectly
conducts the day-to-day operations of the DMEPOS supplier, either under contract or through some other
arrangement, whether or not the individual is a W-2 employee of the DMEPOS supplier.
NOTE: If a governmental or tribal organization will be legally and financially responsible for Medicare
payments received (per the instructions for Governmental/Tribal Organizations in Section 8), the supplier is
only required to report its managing employees in Section 9. Owners, partners, officers, and directors do not
need to be reported.

CMS-855S (09/12)

SECTION 9: OWNERSHIP INTEREST AND/OR MANAGING CONTROL INFORMATION

(INDIVIDUALS) (Continued)
A. INDIVIDUAL IDENTIFICATION INFORMATION (OWNERSHIP AND/OR MANAGING CONTROL)
If you need to report more than one individual, copy and complete this section for each.
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Change

Add

Delete Effective Date (mm/dd/yyyy): _______________________________

1. Complete all identifying information below.
First Name

Middle Initial

Last Name

Social Security Number (Required)

Date of Birth (mm/dd/yyyy)

Supplier Billing Number (if issued)

NPI (if issued)

Telephone Number

Fax Number (if applicable)

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

E-mail Address (if applicable)

2. What is the above individual’s relationship with the supplier in Section 2A? (Check all that apply.)

5 Percent or Greater Direct/Indirect Owner
Partner
Director/Officer

Contracted Managing Employee
Managing Employee (W-2)

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3. What is the above individual’s title? _______________________________________

4. What is the effective date this individual acquired and/or ended ownership or a partnership of the supplier
identified in Section 2A of this application? Furnish both dates if applicable.
Acquired Effective Date (mm/dd/yyyy): _______________________________
Ended Effective Date (mm/dd/yyyy): _______________________________

5. What is the effective date this individual acquired and/or ended managing control (Director, Officer,
Managing Employee) of the supplier identified in Section 2A of this application? Furnish both dates if
applicable.
Acquired Effective Date (mm/dd/yyyy): _______________________________
Ended Effective Date (mm/dd/yyyy): _______________________________
6. Is the above individual also an Delegated Official or Authorized Official?

Delegated Official
Authorized Official
Neither

B. FINAL ADVERSE Legal ACTION HISTORY
Complete this section for the individual reported in Section 9A above.
If you are reporting a change in this section, please check the box and list effective date below.
Change Effective Date (mm/dd/yyyy): _______________________________
1. Has this individual listed in Section 9A, under any current or former name or business entity, ever had a
final adverse legal action listed in Section 7 of this application imposed against it?
YES–Continue Below

NO–Skip to Section 10

Date

Taken By

Resolution

Attach a copy of the final adverse legal action documentation and resolution.
CMS-855S (09/12)

SECTION 10: BILLING AGENCY information
A billing agency is a company or individual that you contract with to prepare and submit your claims. If you
use a billing agency you must complete this section. Even if you use a billing agency, you are responsible for
the accuracy of the claims submitted on your behalf.
Check here if this section does not apply and skip to Section 11.

Billing Agency Name and Address
If you are changing, adding, or deleting information, check the applicable box, furnish the effective date, and
complete the appropriate fields in this section.
Change

Add

Delete Effective Date (mm/dd/yyyy): _______________________________

Legal Business Name as reported to the Internal Revenue Service or Individual Name as Reported to the Social Security Administration
If Individual, Billing Agent Date of Birth (mm/dd/yyyy)
Billing Agency Tax Identification Number or Billing Agent Social Security Number (required)
Billing Agency “Doing Business As” Name (if applicable)

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Billing Agency Address Line 1 (Street Name and Number)
Billing Agency Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Telephone Number

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

Billing Agent/Agency NPI (if issued)

Billing Agent/Agency Medicare Identification Number(s) (if issued)

SECTION 11: CONTACT PERSON Information

If questions arise during the processing of this application, the NSC MAC will contact the individual checked
below.
Contact the Delegated Official reported in Section 14.
Contact the Authorized Official reported in Section 15.
Contact the person reported below.
First Name

Middle Initial

Last Name

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

Address Line 1 (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 this Supplier

Note: The Contact Person reported in this section will only be authorized to discuss issues concerning this
enrollment application. The NSC MAC will not discuss any other enrollment issues for this supplier with the
above Contact Person.
CMS-855S (09/12)

SECTION 12: SUPPORTING Documentation information
This section lists the documents that, if applicable, must be submitted with this completed enrollment
application. If you are newly enrolling, adding a new location, reactivating or revalidating, you must provide
all applicable documents. For changes, only submit documents that are applicable to the change requested.
All enrolling DMEPOS suppliers are required to furnish information on all Federal, State, and local professional
and business licenses, certifications, and/or registrations required to practice as a DMEPOS supplier in the
State of the business location as reported in Section 1A. Check the NSC MAC website for further guidance
on supplier requirements. You are responsible for furnishing and adhering to all required licensure and/or
certification requirements, etc. for the supplies/services you provide.
The enrolling DMEPOS supplier may submit a notarized Certificate of Good Standing from the DMEPOS
supplier’s business location’s State licensing/certification board or other medical associations, in lieu of copies
of the requested documents. This certification cannot be more than 30 days old.
If the enrolling DMEPOS supplier has had a previously revoked or suspended license, certification, or
registration reinstated, attach a copy of the reinstatement notice with this application.

MANDATORY for all new applications and/or additional locations

MANDATORY, IF APPLICABLE

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Copies of all Federal, State, and/or local (city/county) professional and business licenses, certifications
and/or registrations for applicable specialty supplier types, products and services.
Copy of comprehensive liability insurance policy.
Note: The NSC MAC must be listed as the certificate holder.
Written confirmation from the IRS confirming your Tax Identification Number with the Legal Business Name
provided in Section 1B (e.g., IRS form CP 575).
Note: This information is needed if the applicant is enrolling a professional corporation, professional
association, or limited liability corporation with this application or enrolling as a sole proprietor using an
Employer Identification Number.
Completed Form CMS-588, Electronic Funds Transfer Authorization Agreement for each new location.
Include a voided check or letter from your bank.

Copy of IRS Determination Letter, if supplier is registered with the IRS as non-profit (e.g., IRS 501(c)(3)).
Written confirmation from the IRS confirming your business is automatically classified as a Disregarded Entity,
(e.g., IRS Form 8832).
NOTE: A Disregarded Entity is an eligible entity that is not treated as a separate entity from its single owner
for income tax purposes.
Copies of all final adverse legal action documentation (e.g., notifications, resolutions, and reinstatement
letters).
Statement in writing from the bank, if Medicare payments due a supplier are being sent to a bank (or similar
financial institution) where the supplier has a lending relationship (that is, any type of loan), the supplier
must provide a statement in writing from the bank (which must be in the loan agreement) that the bank has
agreed to waive its right of offset for Medicare receivables.
Copy of delegated official’s W-2 if one has been designated.
Copy of your bill of sale if you purchased an existing DMEPOS supplier with an active Medicare supplier
billing number.
Completed Form CMS-460, Medicare Participating Physician or Supplier Agreement, if you want to be a
participating supplier.
Copy of Surety Bond.

CMS-855S (09/12)

SECTION 13: PENALTIES FOR FALSIFYING INFORMATION ON This APPLICATION
This section explains the penalties for deliberately furnishing false information in this application to gain or
maintain enrollment in the Medicare program.

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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.
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.
5. 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.
6. 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.
7. 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.

CMS-855S (09/12)

SECTION 14: DELEGATED OFFICIAL(S) (Optional)
A DELEGATED OFFICIAL means an individual who is delegated by an authorized official the authority to report
changes and updates to the supplier’s enrollment record. The delegated official must be an individual with
“ownership or control interest in” (as that term is defined in Section 1124(a)(3) of the Social Security Act) or be
a W-2 managing employee of the supplier.
Delegated officials may not delegate their authority to any other individual. Only an authorized official may
delegate the authority to make changes and/or updates to the supplier’s Medicare enrollment information.
Even when delegated officials are reported in this application, the authorized official retains the authority to
make changes and/or updates.
You are not required to have a delegated official. However, if no delegated official is assigned, the authorized
official(s) will be the only person(s) who can make changes and/or updates to the enrollment information.
The signature of a delegated official shall have the same force and effect as that of an authorized official,
and shall legally and financially bind the supplier to the laws, regulations, and program instructions of
the Medicare program. By his or her signature, a delegated official certifies that he or she has read the
Certification Statement in Section 15A and agrees to adhere to all of the stated requirements. The delegated
official also certifies that he/she meets the definition of a delegated official. When making changes and/or
updates to the supplier’s enrollment information maintained by the Medicare program, the delegated official
certifies that the information provided is true, correct, and complete.
Independent contractors are not considered “employed” by the supplier. Therefore, an independent
contractor cannot be a delegated official.

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The signature of an authorized official in Section 14 constitutes a legal delegation of authority to all
delegated official(s) assigned in Section 14. If you are delegating more than two individuals, copy and
complete this section for each individual.
Note: A delegated official who is being deleted does not have to sign or date this application.

Assignment of DELEGATED OFFICIAL

All Delegated officials must be reported in Section 9 of this application.

If you are adding or deleting a delegated official, check the applicable box and furnish the effective date.

1st Delegated Official’s Signature
Add
Delete
Effective Date (mm/dd/yyyy): _______________________________
Under penalty of perjury, I the undersigned, certify that I understand and accept the role of Delegated Official.
Middle Initial

Delegated Official First Name (Print)

Last Name

Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)
Telephone Number

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

E-mail Address (if applicable)

Authorized Official’s Signature Assigning this Delegation (First, Middle, Last Name, Jr., Sr., M.D., etc.)

Date Signed (mm/dd/yyyy)

2nd Delegated Official’s Signature
Add
Delete
Effective Date (mm/dd/yyyy): _______________________________
Under penalty of perjury, I the undersigned, certify that I understand and accept the role of Delegated Official.
Delegated Official First Name (Print)

Middle Initial

Last Name

Delegated Official Signature (First, Middle, Last Name, Jr., Sr., M.D., etc.)
Telephone Number

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

E-mail Address (if applicable)

Authorized Official’s Signature Assigning this Delegation (First, Middle, 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.
CMS-855S (09/12)

SECTION 15: CERTIFICATION STATEMENT and authorized official signature
An AUTHORIZED OFFICIAL means an appointed official (for example, chief executive officer, chief financial
officer, general partner, chairman of the board, or direct owner) to whom the organization has granted
the legal authority to enroll it in the Medicare program, to make changes or updates to the organization’s
enrollment information in the Medicare program, and to commit the organization to fully abide by the
statutes, regulations, and program instructions of the Medicare program.
By his/her signature, an authorized official binds the supplier to all of the requirements listed in the
Certification Statement and acknowledges that the supplier may be denied entry to or revoked from the
Medicare program if any requirements are not met. All signatures must be original and in blue ink. Faxed,
photocopied, or stamped signatures will not be accepted.
By signing this application, an authorized official agrees to immediately notify the NSC MAC if any
information in this application is not true, correct, or complete. In addition, an authorized official, by his/
her signature, agrees to notify the NSC MAC of any future changes to the information contained in this
application, after the supplier is enrolled in Medicare, within 30 days of the effective date of the change.
For CMS-855S Enrollment Application(s) submitted for initial enrollment, only the signature of an Authorized
Official will be acceptable for processing the application.
The certification below includes additional requirements that the supplier must meet and maintain to bill
the Medicare program. Read these requirements carefully. By signing, you are attesting to having read the
requirements and understanding them.

A. Certification Statement

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Your signature further stipulates that you agree to adhere to all of the requirements listed below and
acknowledge that you may be denied entry into or revoked from the Medicare program if any requirements
are not met.

You MUST sign and date Section 15B of this 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.

Under penalty of perjury, I the undersigned, certify to the following:
1. 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 NSC MAC of this fact immediately.
2. I agree to notify the NSC MAC of any current or future changes to the information contained in this
application in accordance with the time frames established in 42 C.F.R. § 424.57. I understand that any
change in the business structure of this supplier may require the submission of a new application.
3. 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 denial or revocation of Medicare identification number(s),
and/or the imposition of fines, civil damages, and/or imprisonment.
4. I agree to abide by the Social Security Act and all applicable Medicare laws, regulations and program
instructions that apply to this supplier. 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.
5. Neither this supplier, nor any five percent or greater owner, partner, officer, director, managing employee,
authorized official, or delegated official thereof is currently sanctioned, suspended, debarred, or excluded
by Medicare or State Health Care Program (e.g., Medicaid program), or any other Federal program, or is
otherwise prohibited from supplying services to Medicare or other Federal program beneficiaries.
6. I agree that any existing or future overpayment made to the supplier by the Medicare program may be
recouped by Medicare through the withholding of future payments.
7. I will not knowingly present or cause to be presented a false or fraudulent claim for payment by Medicare,
and will not submit claims with deliberate ignorance or reckless disregard of their truth or falsity.
8. I authorize any national accrediting body whose standards are recognized by the Secretary as meeting the
Medicare program participation requirements, to release to any authorized representative, employee, or
agent of Medicare a copy of my most recent accreditation survey, together with any information related to
the survey that Medicare may require (including corrective action plans).
CMS-855S (09/12)

SECTION 15: CERTIFICATION STATEMENT and authorized official signature
(Continued)
B. AUTHORIZED OFFICIAL SIGNATURE(S)
All Authorized officials must be reported in Section 9 of this application.
If you are adding or deleting an Authorized Official check the applicable box and furnish the effective date.
1st Authorized Official
I have read the contents of this application and the certification statement in Section 15A of this application.
My signature legally and financially binds this supplier to the laws, regulations, and program instructions of
the Medicare program. By my signature, I certify that the information contained herein is true, correct, and
complete, and I authorize the NSC MAC to verify this information.
1st Authorized Official’s Information and Signature
Add
Delete
Effective Date (mm/dd/yyyy): _______________________________
First Name (Print)

Middle Initial

Telephone Number

Last Name

E-mail Address (if applicable)

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

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

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.

2nd Authorized Official

I have read the contents of this application and the certification statement in Section 15A of this application.
My signature legally and financially binds this supplier to the laws, regulations, and program instructions of
the Medicare program. By my signature, I certify that the information contained herein is true, correct, and
complete, and I authorize the NSC MAC to verify this information.

First Name (Print)

2nd Authorized Official’s Information and Signature
Add
Delete
Effective Date (mm/dd/yyyy): _______________________________
Middle Initial

E-mail Address (if applicable)

Telephone Number

Last Name

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

Jr., Sr., M.D., etc.
Title/Position
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.

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 0938-1056. The time required to complete this
information collection is estimated to be 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.
CMS-855S (09/12)

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, 1124A, 1814, 1815, 1833, 1834 and 1866 of the Social Security Act, Sections 501(c) and
3402(t) of the Internal Revenue Code and Section 7701(c) of the United States Code.
The purpose of collecting this information is to determine or verify the eligibility of individuals and
organizations to enroll in the Medicare program as providers and 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 or suppliers 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.

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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 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 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.

CMS-855S (09/12)

File Type	application/pdf
File Modified	2012-06-06
File Created	2012-06-06