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Electronic CMS 855 Forms Available

Electronic and print versions of five Medicare Provider/Supplier Enrollment forms can be obtained from the website of the Centers for Medicare & Medicaid Services (CMS)(external link).

The forms are:

  • Application for Health Care Providers that will Bill Medicare Fiscal Intermediaries (CMS 855A)
  • Application for Health Care Providers that will Bill Medicare Carriers (CMS 855B)
  • Application for Individual Health Care Practitioners (CMS 855I)
  • Application for Individual Reassignment of Benefits (CMS 855R)
  • Application for DMEPOS Suppliers (CMS 855S) [Note: DMERCS must notify the National Supplier Clearinghouse (NSC) of all address changes.]

The CMS website also furnishes a comprehensive user guide with detailed instructions on how to download these applications. Providers and suppliers can complete a form on their computer, save it as a file, and print the completed form for final signature and submission. Providers and suppliers cannot submit these forms electronically at this time.

The CMS 855 is the required form for provider and supplier enrollment in the Medicare program. The forms are used for applying for a Medicare provider number, changing information in an existing Medicare enrollment record, and reassigning Medicare benefits. To change information, providers and suppliers should complete only the first section of the form and those sections that reflect the changes, additions, or deletions.

With the change to the new Form CMS 855, the 1/98 Form HCFA 855C (Change of Information Request) became obsolete. All change requests must be submitted on the appropriate Form CMS 855 with a signed and dated certification statement.

Applications for Iowa, Kansas, Missouri, and Nebraska should be sent to the provider enrollment unit for each state:

Nebraska

WPS Medicare - Provider Enrollment
P.O. Box 8248
Madison, WI 53708

Iowa

WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708

Kansas

WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708

Missouri

WPS Medicare -Provider Enrollment
P.O. Box 8248
Madison, WI 53708

Page Last Updated: Tuesday, 15-Jul-2014 09:21:17 CDT