CMS Pub. 100-08, ch. 10, § 10.1.4

The enrollment applications are available online as well as in paper form:

A. General Overview of Form CMS-855 and CMS-20134

Each Form CMS-855 application is used to enroll a specific provider or supplier type for a

specific purpose.

1. CMS-855A – Medicare Enrollment Application for Institutional Providers

This application should be completed by institutional providers (e.g., hospitals) that will furnish

Medicare Part A services to beneficiaries.

2. CMS-855B –Medicare Enrollment Application for Clinics, Group Practices, and Certain

Other Suppliers

This application should be completed by supplier organizations (e.g., ambulance companies) that

will bill Medicare for Part B services furnished to Medicare beneficiaries. It is not used to enroll

individuals.

3. CMS-855I - Medicare Enrollment Application for Physicians and Non-Physician

Practitioners

This application should be completed by physicians and non-physician practitioners who render

Medicare Part B services to beneficiaries. (This includes a physician or practitioner who is: (1)

the sole owner of a professional corporation, professional association, or limited liability

company and will bill Medicare through this business entity; or (2) a sole proprietor.) (See

section 10.6.4 of this chapter for more information on the business types discussed in this

paragraph.) The CMS-855I captures reassignment information that was previously collected via

the CMS-855R, which has been discontinued.

4. CMS-855S – Medicare Enrollment Application for Durable Medical Equipment,

Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

This application should be completed by DMEPOS suppliers.

5. CMS-855O – Medicare Enrollment Application for Eligible Ordering, Certifying

Physicians, and other Eligible Professionals

This form is used for physicians and other eligible professionals who wish to register in Medicare

solely for the purpose of ordering and certifying the items and services described in 42 CFR §

424.507. These physicians and other eligible professionals do not and will not send claims to a

MAC for any services they furnish.

6. CMS-20134 – Medicare Enrollment Application for Medicare Diabetes Prevention

Program (MDPP) Suppliers

This application should be completed by any supplier organizations that will furnish and bill

Medicare Part B for the MDPP services furnished to Medicare beneficiaries.

B. General Overview of Additional Enrollment Forms

The following forms or form types are routinely submitted with an enrollment application:

1. CMS-588 – Electronic Funds Transfer (EFT) Authorization Agreement

The EFT Agreement authorizes CMS to deposit Medicare payments directly into a

provider/supplier’s bank account.

For Form CMS-855S enrollments, CMS only requires collection of the Form CMS-588 with

initial enrollment applications.

2. CMS-460 – Medicare Participating Physician or Supplier Agreement

This agreement establishes that the Medicare provider/supplier accepts assignment of the

Medicare Part B payment for all services for which the participant is eligible to accept

assignment under the Medicare law and regulations and which are furnished while the agreement

is in effect. The contractor shall explain to the provider or supplier the purpose of the agreement

and how it differs from the actual enrollment process. (This only applies to suppliers that

complete the Forms CMS-855B, CMS-855I and CMS-855S.)

3. CMS Standard Electronic Data Interchange (EDI) Enrollment Form

See CMS Publication 100-04, Medicare Claims Processing Manual, chapter 24, sections 30 -

30.5 for further information.

4. State-Specific Forms for Certified Providers/Certified Suppliers

If the applicant is a certified supplier or certified provider, it will need to contact the state agency

for any state-specific forms and to begin preparations for a state survey. (This does not apply to

those certified entities, such as federally qualified health centers, that do not receive a state

survey.)