Form CMS-855O Enrollment Application

MEDICARE ENROLLMENT APPLICATION
ENROLLMENT FOR ELIGIBLE ORDERING, CERTIFYING
PHYSICIANS, AND OTHER ELIGIBLE
PROFESSIONALS

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
Expires: XX/XX

WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION
Most physicians and eligible professionals (as defined in section 1848(K)(3)(B) of the Social Security Act) 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 eligible professionals to enroll in the Medicare program for the sole purpose of ordering or certifying
items or services for Medicare beneficiaries. These physicians and eligible professionals do not and will not
send claims to a Medicare Administrative Contractor (MAC) for the services they furnish. The physicians and
eligible professionals who may enroll in Medicare solely for the purpose of ordering and certifying include,
but are not limited to, those who are:
•
•
•
•
•
•
•
•
•

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
Employed by Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) or Critical Access
Hospitals (CAH)
Licensed Residents (as defined in 42 C.F.R. section 413.75(b)) in an approved medical residency program
Dentists, including oral surgeons
Pediatricians
Retired physicians who are licensed

Once enrolled, you will be listed on a CMS database and will be deemed eligible to order and certify services
and items for Medicare beneficiaries.
Physicians and eligible professionals can apply to enroll for the sole purpose of ordering and certifying items
and/or services to beneficiaries in the Medicare program or make a change in their enrollment information
using either:
• The CMS-855O application available on the Internet-based Provider Enrollment, Chain and Ownership
System (PECOS), or
• The paper CMS-855O application. Be sure you are using the most current version.
For additional information regarding the Medicare ordering and certifying enrollment process, including
Internet-based PECOS and to get a copy of the most current CMS-855O application, go to https://
www.cms.gov/MedicareProviderSupEnroll.
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
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). You must obtain an
NPI prior to enrolling in Medicare. Applying for the NPI is a process separate from Medicare enrollment. To
obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov/NPPES/Welcome.do. For more information
about NPI enumeration, visit http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/
MedicareProviderSupEnroll/index.html.

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INSTRUCTIONS FOR COMPLETING THIS APPLICATION
All information on this form is required with the exception of those fields specifically marked as “optional.”
Any field marked as optional is not required to be completed nor does it need to be updated or reported as a
“change of information” as required in 42 C.F.R section 424.516. However, it is highly recommended that once
reported, these fields be kept up-to-date.
• Type or print all information so that it is legible. Do not use pencil.
• Complete all applicable sections and furnish your NPI.
• Keep a copy of your completed Medicare enrollment application for your records.
• Sign and date Section 8 of this application using ink.

ACRONYMS COMMONLY USED IN THIS APPLICATION
MAC: Medicare Administrative Contractor
NPI: National Provider Identifier
PECOS: Provider Enrollment Chain and Ownership System

WHERE TO MAIL YOUR APPLICATION
The MAC that services your state is responsible for processing your enrollment 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
A. REASON FOR SUBMITTING THIS APPLICATION

Check one box and complete the sections of this application as indicated.
You are enrolling for the sole purpose of ordering/certifying

Complete all sections

You are currently enrolled solely to order and certify, and are
updating your information

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

You are voluntarily withdrawing your Medicare enrollment to
solely order and certify

Complete Section 2A (Name, SSN
and NPI) and Section 8

B. REASON YOU ARE ENROLLING SOLELY TO ORDER AND CERTIFY
Instructions: Choose only one reason from Group One OR one reason from Group Two
You are enrolling in Medicare solely to order and certify because you are:

Group 1

Group 2

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 entity in Group 1
Eligible Professional not employed by any entity in
Group 1
Licensed Resident not employed by any entity in
Group 1
Dentist not employed by any entity in Group 1
Pediatrician not employed by any entity in Group 1

Retired physicians who are not licensed
Other (specify):

SECTION 2: IDENTIFYING INFORMATION
A. PERSONAL INFORMATION

Your name, date of birth, and social security number must match your social security record.
First Name

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
Social Security Number (SSN)

Professional Name

Other (Describe):

Date of Birth (mm/dd/yyyy)

Gender
Male

Medicare Identification Number (PTAN) (if issued)

Female

National Provider Identifier (NPI) (Type 1 – Individual)

B. EDUCATIONAL INFORMATION
Medical or other Professional School (Training Institution, if non-MD)

Year of Graduation (yyyy)

C. LICENSE/CERTIFICATION/REGISTRATION 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) Registration Information
Registration Not Applicable
DEA Registration Number

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Effective Date (mm/dd/yyyy)

State Where Issued

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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

1. Any federal or state felony convictions (as defined in 42 C.F.R. section 1001.2) within the preceding
10 years.
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 and/or Medicaid billing number.
5. Any Medicare and/or Medicaid revocation of any Medicare and/or Medicaid billing numbers.

C. FINAL ADVERSE LEGAL ACTION HISTORY

If you are reporting a change in this section, check the box below and furnish the effective date.
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.
Attach a copy of the relevant final legal adverse action documents.
FINAL ADVERSE LEGAL ACTION

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TAKEN BY

RESOLUTION

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SECTION 4: MEDICAL SPECIALTY INFORMATION
A. PHYSICIAN SPECIALTY

Check your primary specialty below. Only check one (1) specialty. Physicians must meet all state requirements
for the type of specialty checked.
Addiction Medicine
Allergy/Immunology
Anesthesiology
Cardiac Electrophysiology
Cardiac Surgery
Cardiovascular Disease (Cardiology)
Colorectal Surgery (Proctology)
Critical Care (Intensivists)
Dentist
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/Palliative Care
Infectious Disease
Internal Medicine
Interventional Cardiology
Interventional Pain Management
Interventional Radiology
Maxillofacial Surgery
Medical Oncology

Nephrology
Neurology
Neuropsychiatry
Neurosurgery
Nuclear Medicine
Obstetrics/Gynecology
Ophthalmology
Optometry
Oral Surgery
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 Medicine
Sports Medicine
Surgical Oncology
Thoracic Surgery
Urology
Vascular Surgery
Undefined Physician Specialty
(Specify):

B. ELIGIBLE PROFESSIONAL OR OTHER NON-PHYSICIAN SPECIALTY TYPE

If you are an eligible professional (as defined in section 1848(K)(3)(B) of the Social Security Act), check the
appropriate box to indicate your specialty.
All individuals 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
Nurse Practitioner
Occupational Therapist
Physical Therapist
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Physician Assistant
Qualified Audiologist
Qualified Speech-Language Pathologist
Registered Dietician or Nutritional Professional
Unlisted Practitioner Type
(Specify):

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SECTION 5: IMPORTANT ADDRESS INFORMATION
CORRESPONDENCE MAILING ADDRESS

Once you are enrolled, the MAC will use the address and contact information in this section if it needs to
contact you directly.
Business Location Name
Attention (optional)
Mailing Address Line 1 (P.O. Box or Street Name and Number)
Mailing Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

ZIP Code + 4

Telephone Number

Fax Number (if applicable)

E-mail Address (if applicable)

SECTION 6: CONTACT PERSON INFORMATION (Optional)
If questions arise during the processing of only this application, your designated MAC will attempt to contact
the individual you list in this section. All other inquiries will be directed to the contact listed in section 5.
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: During the enrollment process, the MAC may request documentation to support and validate
information reported on this application. You must provide this documentation in a timely manner.

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SECTION 7: 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.
1. 18 U.S.C. section 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. section 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. section 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;
c) conspires to defraud the Government by getting a false or fraudulent claim allowed or paid.
The Act imposes a civil penalty of $5,000 to $10,000 per violation, plus three times the amount of damages
sustained by the Government
4. Section 1128A(a)(1) of the Social Security Act imposes civil liability, in part, on any person (including an
organization, agency or other entity) that knowingly presents or causes to be presented to an officer,
employee, or agent of the United States, or of any department or agency thereof, or of any State
agency…a claim…that the Secretary determines is for a medical or other item or service that the person
knows or should know:
a) was not provided as claimed; and/or
b) the claim is false or fraudulent.
5. This provision authorizes a civil monetary penalty of up to $10,000 for each item or service, an assessment
of up to three times the amount claimed, and exclusion from participation in the Medicare program and
State health care programs.
6. 18 U.S.C. 1035 authorizes criminal penalties against individuals in any matter involving a health care
benefit program who knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device
a material fact; or makes any materially false, fictitious, or fraudulent statements or representations,
or makes or uses any materially false fictitious, or fraudulent statement or entry, in connection with
the delivery of or payment for health care benefits, items or services. The individual shall be fined or
imprisoned up to 5 years or both.
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 enrollment
in the Medicare program solely to order and certify 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 enrolling in the Medicare program if any requirements
are not met.

A. CERTIFICATION STATEMENT

You MUST SIGN AND DATE the certification statement below in order to be enrolled in the Medicare program.
In doing so, you are attesting to meeting and maintaining the Medicare requirements stated below.
Under the penalty of perjury, 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.
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.
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.
5. I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to
the organization listed in Section 2A of this application. The Medicare laws, regulations, and program
instructions are available through the fee-for-service 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,
42 U.S.C. section 1320a-7b(b) (section 1128B(b) of the Social Security Act) and the Physician Self-Referral
Law (Stark Law), 42 U.S.C. section 1395nn (section 1877 of the Social Security Act)).
6. I will not knowingly order and/or certify 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 certifying items or services to Medicare beneficiaries, and I have signed and dated this application.

B. SIGNATURE AND DATE
First Name (Print)

Middle Initial

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

Last Name (Print)

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

All signatures must be original. Applications with signatures deemed not original or not dated will not be processed.

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

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT
The Authority for maintenance of the system is given under provisions of sections 1102(a) (Title 42 U.S.C. 1302(a)),
1128 (42 U.S.C. 1320a–7), 1814(a)) (42 U.S.C. 1395f(a)(1), 1815(a) (42 U.S.C. 1395g(a)), 1833(e) (42 U.S.C. 1395I(3)),
1871 (42 U.S.C. 1395hh), and 1886(d)(5)(F), (42 U.S.C. 1395ww(d)(5)(F) of the Social Security Act; 1842(r) (42 U.S.C.
1395u(r)); section 1124(a)(1) (42 U.S.C. 1320a–3(a)(1), and 1124A (42 U.S.C. 1320a–3a), section 4313, as amended, of
the BBA of 1997; and section 31001(i) (31 U.S.C. 7701) of the DCIA (Pub. L. 104–134), as amended.
The information collected here will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
PECOS will collect information provided by an applicant related to identity, qualifications, practice locations,
ownership, billing agency information, reassignment of benefits, electronic funds transfer, the NPI and related
organizations. PECOS will also maintain information on business owners, chain home offices and provider/chain
associations, managing/ directing employees, partners, authorized and delegated officials, supervising physicians
of the supplier, ambulance vehicle information, and/or interpreting physicians and related technicians. This system
of records will contain the names, social security numbers (SSN), date of birth (DOB), and employer identification
numbers (EIN) and NPI’s for each disclosing entity, owners with 5 percent or more ownership or control interest, as
well as managing/directing employees. Managing/directing employees include general manager, business managers,
administrators, directors, and other individuals who exercise operational or managerial control over the provider/
supplier. The system will also contain Medicare identification numbers (i.e., CCN, PTAN and the NPI), demographic
data, professional data, past and present history as well as information regarding any adverse legal actions such as
exclusions, sanctions, and felonious behavior.
The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used
for a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure
of data is known as a “routine use.” The CMS will only release PECOS information that can be associated with
an individual as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both
identifiable and non-identifiable data may be disclosed under a routine use. CMS will only collect the minimum
personal data necessary to achieve the purpose of PECOS. Below is an abbreviated summary of the six routine
uses. To view the routine uses in their entirety go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/
PrivacyActSystemofRecords/Systems-of-Records-Items/CMS023307.html.
1. To support CMS contractors, consultants, or grantees, who have been engaged by CMS to assist in the
performance of a service related to this collection and who need to have access to the records in order to
perform the activity.
2. To assist another federal or state agency, agency of a state government or its fiscal agent to:
a. Contribute to the accuracy of CMS’s proper payment of Medicare benefits,
b. Enable such agency to administer a federal health benefits program that implements a health benefits
program funded in whole or in part with federal funds, and/or
c. Evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance
operations.
3. To assist an individual or organization for research, evaluation or epidemiological projects related to the
prevention of disease or disability, or the restoration or maintenance of health, and for payment related
projects.
4. To support the Department of Justice (DOJ), court or adjudicatory body when:
a. The agency or any component thereof, or
b. Any employee of the agency in his or her official capacity, or
c. Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the
employee, or
d. The United States Government, is a party to litigation and that the use of such records by the DOJ, court or
adjudicatory body is compatible with the purpose for which CMS collected the records.
5. To assist a CMS contractor that assists in the administration of a CMS administered health benefits program, or
to combat fraud, waste, or abuse in such program.
6. To assist another federal agency to investigate potential fraud, waste, or abuse in, a health benefits program
funded in whole or in part by federal funds.
The applicant 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. section 552a, to permit the government to verify information through computer
matching.
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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