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
page 2 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 SUBMIT THIS APPLICATION
Physicians and eligible professionals can apply to enroll for the sole purpose of ordering or certifying items
and/or services to beneficiaries in the Medicare program, or make a change in their ordering/certifying
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/certifying enrollment process, including
Internet-based PECOS and to obtain a copy of the most current CMS-855O application, go to
CMS.gov/Medicare/Provider-Enrollment-and-Certification.
NOTE: For purposes of this application only, the word “provider” is used universally and includes any providers
or suppliers who are required to complete the CMS-855O 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/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/certifying include, but are not
limited to, those who are:
• Employed by the Department of Veterans Affairs (DVA)
• Employed by the Department of Defense (DOD)/Tricare (moved from list below so the first two bullets are
military related while the rest of the bullets are from HHS (ASPE))
• Employed by the Public Health Service (PHS)
• 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/certify services and
items for Medicare beneficiaries.
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.

BILLING NUMBER AND NATIONAL PROVIDER IDENTIFIER INFORMATION
The Provider Transaction Access Number (PTAN), often referred to as a Medicare Provider Number or Medicare
Billing Number, is a generic term for any number other than the National Provider Identifier (NPI) that is used
by a provider 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 enroll in
Medicare, 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 NPPES.cms.hhs.gov. For more
information about NPI enumeration, visit CMS.gov/Regulations-and-Guidance/Administrative-Simplification/
NationalProvIdentStand/enumeration.
NOTE: The Legal Business Name (LBN) and Tax Identification Number (TIN) that you furnish in section 2A must
be the same LBN and TIN you used to obtain your NPI. Once this information is entered into PECOS from this
application, your LBN, TIN and NPI must match exactly in both PECOS and NPPES.
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INSTRUCTIONS FOR COMPLETING AND SUBMITTING 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 if
once reported, these fields be kept up-to-date.
• This form must be typed. It may not be handwritten. If portions of this form are handwritten, the MAC may
return this application to you.
• When necessary to report additional information, copy and complete the applicable section as needed.
• Keep a copy of your completed Medicare enrollment package for your own records.

TIPS TO AVOID DELAYS IN YOUR ENROLLMENT
To avoid delays in the enrollment process, you should:
•
•
•
•
•

Complete all required sections, as shown in section 1.
Ensure that the name shown in section 2 matches the name on your social security record.
Enter your NPI in section 2.
Sign and date section 8 using ink.
Ensure all supporting documents are sent to your designated MAC.

ADDITIONAL INFORMATION
You may visit our website to learn more about the enrollment process via the Internet-Based Provider
• Enrollment Chain and Ownership System (PECOS) at: CMS.gov/Medicare/Provider-Enrollment-andCertification. All of the CMS-855 applications are located on the CMS webpage: CMS.gov/medicare/cmsforms/cms-forms/cms-forms-list.html. Simply enter “855” in the “Filter On:” box on this page and only the
application forms will be displayed to choose from.
• The MAC may request additional documentation to support and validate information reported on this
application. You are responsible for providing this documentation within 30 days of the request per
42 C.F.R. section 424.525(a)(1).
• The information you provide on this form is protected under 5 U.S.C. section 552(b)(4) and/or (b)(6),
respectively. For more information, see the last page of this application to read the Privacy Act Statement.

ACRONYMS COMMONLY USED IN THIS APPLICATION
C.F.R.: Code of Federal Regulations
MAC: Medicare Administrative Contractor
NPI: National Provider Identifier
NPPES: National Plan and Provider Enumeration System
PECOS: Provider Enrollment Chain and Ownership System
PTAN: Provider Transaction Access Number also referred to as the Medicare Identification Number
SSN: Social Security Number

WHERE TO MAIL YOUR APPLICATION
Send this completed application with original signatures and all required documentation to your designated
MAC. The MAC that services your state is responsible for processing your enrollment application. To locate the
mailing address for your designated MAC, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.

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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/certify and are updating your Complete section 2A, all other

applicable sections and section 8

information

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

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

B. REASON YOU ARE ENROLLING SOLELY TO ORDER/CERTIFY
Instructions: Choose only one reason from Group 1 OR one reason from Group 2
You are enrolling in Medicare solely to order/certify and you are:
Group 1:
Group 2:
Employed by the DVA
Physician not employed by any entity in Group 1
Employed by the PHS
Eligible Professional not employed by any entity in
Group 1
Employed by the DOD/Tricare

Licensed Resident not employed by any entity in
Employed by the IHS or a Tribal Organization
Group 1
Employed by a Medicare-enrolled FQHC

Dentist
not employed by any entity in Group 1
Employed by a Medicare-enrolled RHC
Pediatrician not employed by any entity in Group 1
Employed by a Medicare-enrolled CAH
Retired physicians who are 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)

Do you owe an existing debt to CMS?..................................................................................................................................

Yes 

No

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

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Year of Graduation (yyyy)

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SECTION 2: IDENTIFYING INFORMATION (Continued)
C. LICENSE/CERTIFICATION INFORMATION
Complete the appropriate subsection(s) below for your physician specialty reported in section 4A or 4B. If no
subsection is associated with your physician specialty, check the box stating the information is not applicable.
*If you are certified by a national entity, put the word “all” in the “State Where Issued” data field.

Active License Information
License Not Applicable
License Number

Effective Date (mm/dd/yyyy)

State Where Issued*

Effective Date (mm/dd/yyyy)

State Where Issued*

Active Certification Information
Certification Not Applicable
Certification Number

Certifying Entity (Specialty Board, State, Other)

Drug Enforcement Agency (DEA) Registration Information
DEA Registration Not Applicable
DEA Registration Number

CMS-855O (XX/XX)

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, license
revocations and license suspensions. All applicable final adverse legal actions must be reported, regardless of
whether any records were expunged or any appeals are pending.
NOTE: To satisfy the reporting requirement, section 3 must be filled out in its entirety, and all applicable
attachments must be included.

A. FEDERAL AND STATE CONVICTIONS (CONVICTION AS DEFINED IN 42 C.F.R. SECTION 1001.2)
WITHIN THE PRECEDING 10 YEARS
1. Any federal or state felony conviction(s).
2. Any crime, under federal or state law, which received a sentence of deferred adjudication, adjudication
withheld, stay of adjudication, withholding of judgment, or order of deferral—regardless of whether the
court dismissed the case upon completion of probation, and regardless of whether the felony was reduced
to a misdemeanor.
3. 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.
4. 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.
5. Any misdemeanor conviction, under federal or state law, related to the unlawful manufacture, distribution,
prescription, or dispensing of a controlled substance.
6. Any 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.

B. EXCLUSIONS, REVOCATIONS OR SUSPENSIONS
1. Any current or past revocation, suspension, or voluntary surrender of a medical license in lieu of further
disciplinary action.
2. Any current or past revocation or suspension of accreditation.
3. Any current or past suspension or exclusion imposed by the U.S. Department of Health and Human Service’s
Office of Inspector General (OIG).
4. Any current or past debarment from participation in any Federal Executive Branch procurement or
non-procurement program.
5. Any other current or past federal sanctions (A penalty imposed by a federal governing body (e.g. Civil
Monetary Penalties (CMP)).
6. Any Medicaid exclusion, enrollment suspension, payment suspension, revocation, or termination of any
billing number.

C. FINAL ADVERSE LEGAL ACTION HISTORY
1. Have you, under any current or former name or business identity, 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, and the federal or state agency or the
court/administrative body that imposed the action.
FINAL ADVERSE LEGAL ACTION

CMS-855O (XX/XX)

DATE

ACTION TAKEN BY

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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 federal and state
requirements for the type of specialty checked.
Addiction Medicine
Adult Congenital Heart Disease
Advanced Heart Failure and Transplant Cardiology
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
Hematopoietic Cell Transplantation and
Cellular Therapy
Hospice/Palliative Care
Hospitalist
Infectious Disease
Internal Medicine
Interventional Cardiology
Interventional Pain Management
Interventional Radiology
Maxillofacial Surgery
Medical Genetics and Genomics

Medical Oncology
Medical Toxicology
Micrographic Dermatologic Surgery
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
Undersea and Hyperbaric Medicine
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
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Clinical Social Worker
Nurse Practitioner
Physician Assistant

Unlisted Practitioner Type
(Specify):
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SECTION 5: CORRESPONDENCE ADDRESS INFORMATION
CORRESPONDENCE MAILING ADDRESS
This is the address where correspondence will be sent to you by your designated MAC. This address cannot be
a billing agent or agency’s address or a medical management company address. If you are reporting a change
to your correspondence mailing address, check the box below. This will replace any current correspondence
mailing address on file.
Change

Effective Date (mm/dd/yyyy):

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 this application, your designated MAC will attempt to contact the
individual you list in this section.
First Name

Middle Initial

Last Name

Jr., Sr., MD., etc.

Address Line 1 (P.O. Box or Street Name and Number)

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

City/Town

Telephone Number

State

Fax Number (if applicable)

ZIP Code + 4

E-mail Address (if applicable)

Relationship or Affiliation to You

NOTE: The contact person listed in this section will only be authorized to discuss issues concerning this
particular CMS-855O application. Your designated MAC will not discuss any other Medicare issues about you
with the above Contact Person.

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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, with
actual knowledge, deliberate ignorance or reckless disregard of truth or falsity (a) presents or causes to
be presented to the United States Government or its contractor or agent a false or fraudulent claim for
payment or approval; (b) uses or causes to be used a false record or statement material either to a false or
fraudulent claim or to an obligation to pay the Government; (c) conceals or improperly avoids or decreases
an obligation to pay or transmit money or property to the Government; or (d) conspires to violate any
provision of the False Claims Act. The False Claims Act imposes a civil penalty of between $5,000 and
$10,000 per violation, as adjusted for inflation by the Federal Civil Penalties Inflation Adjustment Act,
28 U.S.C. 2461, plus three times the amount of damages sustained by the Government.
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/certify items and services for Medicare beneficiaries, or prescribe
Part D drugs. 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 Medicare contractor
of any future changes to the information contained in this application in accordance with the timeframes
established in 42 C.F.R. section 424.516. I understand that any change to my status as an individual
practitioner may require the submission of a new application.
4. I have read and understand the Penalties for Falsifying Information, as printed in this application. I
understand that any deliberate omission, misrepresentation or falsification of any information contained in
this application or contained in any communication supplying information to Medicare, or any deliberate
alteration of any text on this application form, may be punished by criminal, civil, or administrative
penalties including, but not limited to the imposition of fines, civil damages and/or imprisonment.
5. I agree to abide by 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 Medicare Administrative 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/
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)

In order to process this application it MUST be signed and dated.

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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: 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 information you provide on this form may be verified 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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