- 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
- 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 Historical Information Request (PEHIR)
- 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
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Last Updated Apr 12, 2018