The following forms can be used for initial enrollment, revalidations, changes in status, and voluntary termination:

• CMS-855A (PDF) for Institutional Providers
• CMS-855B (PDF) for Clinics, Group Practices, and Certain Other Suppliers
• CMS-855I (PDF) for Physicians and Non-Physician Practitioners
• CMS-855O (PDF) for Ordering and Certifying Physicians and Non-Physician Practitioners
• CMS-855S (PDF) for DMEPOS Suppliers
  CMS is currently revising the 855S to reflect the new DMEPOS enrollment contractors and their mailing addresses. Effective Nov. 7, 2022, the National Supplier Clearinghouse no longer processes enrollment applications for DMEPOS suppliers. DMEPOS suppliers should send their 855S applications and related forms to their region's new enrollment contractor. Find your enrollment contractor (PDF).
• CMS-20134 (PDF) for MDPP Suppliers

The following forms are routinely submitted with an enrollment application:

• Electronic Funds Transfer (EFT) Authorization Agreement (Form CMS-588 (PDF))
• Medicare Participating Physician or Supplier Agreement (Form CMS-460 (PDF))

Submit Your Application

When you’ve completed your paper application, print it and sign it. Your signature must be handwritten when you submit a paper application. Make a copy of the signed form for your records before mailing it to your enrollment contractorⁱ with your supporting documents and EFT Authorization Agreement form.

Find your enrollment contractor (PDF).