MEDICARE ENROLLMENT APPLICATION - CMS

MEDICARE ENROLLMENT APPLICATION . Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers CMS-855S. SEE PAGE 1 FOR A LIST OF THE DMEPOS SUPPLIER STANDARDS. TO ENROLL IN THE MEDICARE . PROGRAM AND BE ELIGIBLE TO SUBMIT CLAIMS AND RECEIVE PAYMENTS, EVERY DMEPOS SUPPLIER. APPLICANT MUST MEET AND MAINTAIN THESE ENROLLMENT STANDARDS. SEE PAGE 2 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION . SEE PAGE 4 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION . SEE SECTION 12 FOR A LIST OF SUPPORTING DOCUMENTATION TO BE SUBMITTED WITH THIS. APPLICATION . TO VIEW YOUR CURRENT MEDICARE ENROLLMENT RECORD GO TO: Form Approved DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB No. 0938-1056. CENTERS FOR MEDICARE & MEDICAID SERVICES Expires: 05/19. DMEPOS SUPPLIER STANDARDS FOR MEDICARE ENROLLMENT . Below is an abbreviated summary of the standards every MEDICARE DMEPOS supplier must meet in order to obtain and retain their billing privileges.

DMEPOS suppliers 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 CMS-855S enrollment application. Be sure you are using the most current version.

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