Medicare Enrollment Application form for all Physicians and Non-Physician Practitioners

You are encouraged to begin using this form immediately (May 1, 2006).

MLN Matters Information Document on Enrollment Application Form 855.

CMS Medicare Enrollment Application Form 855I (click here to download form)

All physicians, as well as all non-physician practitioners listed below, must complete this application to
initiate the enrollment process:

Anesthesiology Assistant Occupational therapist in private practice
Audiologist Physical therapist in
private practice
Certified nurse midwife Physician assistant
Certified registered nurse anesthetist Psychologist, Clinical
Clinical nurse specialist
Clinical social worker Psychologist billing independently
Mass immunization roster biller Registered Dietitian or Nutrition Professional
Nurse practitioner  

If your supplier type is not listed above, contact the fee-for-service contractor before you submit
this application.

Complete this application if you are an individual practitioner who plans to bill Medicare and you are:

• An individual practitioner who will provide services in a private setting.
• An individual practitioner who will provide services in a group setting. If you plan to render all of
your services in a group setting, you will complete Sections 1-4 and skip to Sections 14 through 17
of this application.
• Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-forservice
contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory
serviced by another Medicare fee-for-service contractor).
• Currently enrolled in Medicare and need to make changes to your enrollment information (e.g., you
have added or changed a practice location).
• An individual who has formed a professional corporation, professional association, limited liability
company, etc., of which you are the sole owner.

If you provide services in a group/organization setting, you will also need to complete a separate
application, the CMS-855R, to reassign your benefits to each organization. If you terminate your
association with an organization, use the CMS-855R to submit that change.

If you perform diagnostic testing, you may be required to enroll as an Independent Diagnostic Testing
Facility (IDTF) if substantial portions of your diagnostic tests (other than clinical laboratory or pathology)
are provided to patients who are not your patients. Check with your Medicare fee-for-service contractor to
determine whether or not you need to enroll as an IDTF. If you only furnish diagnostic tests, claims must
be submitted as an IDTF and you must complete and submit the CMS-855B.