Transcription of Medicare Enrollment Application
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Medicare Enrollment Application
Medicare Enrollment Application Clinics/group Practices and Certain other Suppliers CMS-855B See Page 1 to deterMine if you are CoMPleting the CorreCt Application . See Page 2 for inforMation on where to Mail thiS Application . See Page 35 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 Form Approved OMB NO. 0938-0685 Expires: 08/19 who Should SuBMit thiS Application Clinics and group practices 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 ( , CMS 855B).For additional information regarding the Medicare Enrollment process, including Internet-based PECOS, go to Clinics and group practices who are enrolled in the Medicare program, but have not submitted the CMS 855B since 2003, are required to submit a Medicare Enrollment Application ( , Internet-based PECOS or the CMS 855B) as an initial Application when reporting a change for the first time.
Clinics and group practices 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 855B).
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