MEDICARE ENROLLMENT APPLICATION
SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION
SEE PAGE 3 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION.
SEE PAGE 52 TO FIND A LIST OF THE SUPPORTING DOCUMENTATION THAT MUST BE
SUBMITTED WITH THIS APPLICATION.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0685
WHO SHOULD COMPLETE THIS APPLICATION
Institutional providers 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
• The paper enrollment application process (e.g., CMS 855A).
For additional information regarding the Medicare enrollment process, including Internet-based PECOS,
go to www.cms.gov/MedicareProviderSupEnroll.
Institutional providers who are enrolled in the Medicare program, but have not submitted the CMS 855A