Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I)

OMB 0938-1355

The primary function of the CMS-855I Medicare enrollment application for physicians and non-physician practitioners is to gather information from an individual provider or supplier that tells us who he/she is, whether he/she meets certain qualifications to be a Medicare health care provider or supplier, where he/she practices or renders services, and other information necessary to establish correct claims payments.

The latest form for Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I) expires 2021-12-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-855i Voluntary Termination of Medicare Enrollment Form and Instruction
Form CMS-855i Reporting a Change Form and Instruction
Form CMS-855i Switching Provider Type/MAC Form and Instruction
Form CMS-855I Revalidation Form and Instruction
Form CMS-855i Reactivation Form and Instruction
Form CMS-855i Initial Enrollment Form and Instruction
CMS-855I Supporting Statement.docx Supporting Statement A
Voluntary Termination of Medicare Enrollment Form and Instruction
Reporting a Change Form and Instruction
Switching Provider Type/MAC Form and Instruction
Revalidation Form and Instruction
Reactivation Form and Instruction
Initial Enrollment Form and Instruction

All Historical Document Collections

202301-0938-009 Approved without change	Reinstatement without change of a previously approved collection	2023-02-28
201807-0938-006 Approved without change	New collection (Request for a new OMB Control Number)	2018-08-02

OMB Details

Initial Enrollment

Federal Enterprise Architecture: Health - Health Care Services

Form CMS-855i

Medicare Enrollment Application

Fillable Printable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.