- CMS 460 - Medicare Participating Physician or Supplier Agreement
- CMS 588 - Authorization Agreement for Electronic Funds Transfer (EFT)
- CMS 588 EFT Instructions
- CMS 855B - Clinics, Group Practices, and Certain Other Suppliers
- CMS 855I - Individual Practitioners
- CMS 855I Instructions
- CMS 855R - Reassignment of Benefits
- CMS 855R Instructions
- CMS 8550 - Eligible Ordering, Certifying and Prescribing Physicians, and Other Eligible Professionals
- CMS 20134 - Medicare Diabetes Prevention Program (MDPP) Suppliers
- Laboratories Billing for Referred Tests - Self Attestation [PDF]
- Opt Out - Affidavit [PDF]
- Opt Out - Private Contract [PDF]
- Provider Enrollment Corrective Action Plan (CAP) Cover Sheet [PDF] - Request a Provider CAP. Must be submitted within 30 days from date of denial or revocation notice
- Provider Enrollment Reconsideration (Appeal) Form [PDF] - Appeal Provider Enrollment's decision on application. Request must be submitted within 30 to 60 days from date of denial letter
Due to varying Internet Browsers and versions of Adobe, users may receive the error message, "Adobe PDF Document. There is a problem with Adobe Acrobat/Reader. If it is running, exit, and try again. (0:104)"
If this occurs, close the error message and use the browser "refresh" button, or press the F5 key, to reload the PDF.
Interactive Form Tips
Select "Highlight fields" and/or "Highlight required fields" to ensure all form fields are completed.
To view field instructions (including CMS supplied instructions, when provided), hover over desired field.
Blank and completed forms may be saved to a user's computer. Right-click PDF hyperlink and select "Save as."
Electronic completion minimizes possibility of illegible handwritten forms.
Last Updated Oct 25, 2018