Applications and Forms
CMS-20134
CMS-855B
CMS-855I
CMS-855O
Electronic Funds Transfer Agreement CMS-588 (EFT)
Interactive Help Tool
Opt Out Affidavit Form
Participating Providers Agreement CMS-460 (PAR)
Authorized and Delegated Officials
Organizational Structure Application Requirements
The Internet-based Provider Enrollment, Chain and Ownership System (Internet-based PECOS) can be used in lieu of the Medicare enrollment application (i.e., paper CMS-855) to:
- Submit an initial Medicare enrollment application
- View or change your enrollment information
- Track your enrollment application through the web submission process
- Add or change a reassignment of benefits
- Submit changes to existing Medicare enrollment information
- Reactivate an existing enrollment record
- Withdraw from the Medicare Program
- Submit a Change of Ownership (CHOW) of the Medicare-enrolled provider
Advantages of Internet-based PECOS
- Faster than paper-based enrollment (45 day processing time in most cases, vs. 60 days for paper)
- Tailored application process means you only supply information relevant to YOUR application
- Gives you more control over your enrollment information, including reassignments
- Easy to check and update your information for accuracy
- Less staff time and administrative costs to complete and submit enrollment to Medicare