Form Cms-8550 - Medicare Enrollment Application Page 2

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Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-1135
CENTERS FOR MEDICARE & MEDICAID SERVICES
Expires: 01/20
WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION
Most physicians and eligible professionals (as defined in section 1848(K)(3)(B) of the Social Security Act) enroll
in the Medicare program to be reimbursed for the covered services they furnish to Medicare beneficiaries.
However, with the implementation of Section 6405 of the Affordable Care Act, CMS requires certain physicians
and eligible professionals to enroll in the Medicare program for the sole purpose of ordering or certifying
items or services for Medicare beneficiaries, and prescribing Part D drugs. These physicians and eligible
professionals do not and will not send claims to a Medicare Administrative Contractor (MAC) for the services
they furnish. The physicians and eligible professionals who may enroll in Medicare solely for the purpose of
ordering and certifying and prescribing Part D drugs include, but are not limited to, those who are:
• Employed by the Department of Veterans Affairs (DVA)
• Employed by the Public Health Service (PHS)
• Employed by the Department of Defense (DOD)/Tricare
• Employed by the Indian Health Service (IHS) or a Tribal Organization
• Employed by Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC) or Critical Access
Hospitals (CAH)
• Licensed Residents (as defined in 42 C.F.R. section 413.75(b)) in an approved medical residency program
• Dentists, including oral surgeons
• Pediatricians
• Retired physicians who are licensed
Once enrolled, you will be listed on a CMS database and will be deemed eligible to order and certify services
and items or prescribe Part D drugs for Medicare beneficiaries.
Physicians and eligible professionals can apply to enroll for the sole purpose of ordering and certifying items
and/or services to beneficiaries, and prescribing Part D drugs in the Medicare program or make a change in
their enrollment information using either:
• The CMS-855O application available on the Internet-based Provider Enrollment, Chain and Ownership
System (PECOS), or
• The paper CMS-855O application. Be sure you are using the most current version.
For additional information regarding the Medicare ordering and certifying and Part D prescribing enrollment
process, including Internet-based PECOS and to get a copy of the most current CMS-855O application, go to
https://
The information you provide on this form will not be shared. It is protected under 5 U.S.C. Section 552(b)(4)
and/or (b)(6), respectively. See the last page of this application to read the Privacy Act Statement.
NATIONAL PROVIDER IDENTIFIER INFORMATION
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers and
suppliers and is assigned by the National Plan and Provider Enumeration System (NPPES). You must obtain an
NPI prior to enrolling in Medicare. Applying for the NPI is a process separate from Medicare enrollment. To
obtain an NPI, you may apply online at https://NPPES.cms.hhs.gov/NPPES/Welcome.do. For more information
about NPI enumeration, visit
MedicareProviderSupEnroll/index.html.
CMS-855O (01/17)
1

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