Form Cms-855a - Medicare Enrollment Application - Institutional Providers Page 2
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54Form Approved OMB
No.
0938-0685
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Expires: 08/19
CENTERS FOR MEDICARE & MEDICAID SERVICES
WHO SHOULD COMPLETE THIS APPLICATION
Institutional providers can apply for enrollment in the Medicare program or make a change in their
enrollment information using either:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• The paper enrollment application process (e.g., CMS 855A).
For additional information regarding the Medicare enrollment process, including Internet-based PECOS,
go to
Institutional providers who are enrolled in the Medicare program, but have not submitted the CMS 855A
since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the
CMS 855A) as an initial application when reporting a change for the first time.
The following health care organizations must complete this application to initiate the enrollment process:
• Community Mental Health Center
• Hospital
• Comprehensive Outpatient Rehabilitation Facility • Indian Health Services Facility
• Critical Access Hospital
• Organ Procurement Organization
• End-Stage Renal Disease Facility
• Outpatient Physical Therapy/Occupational
• Federally Qualified Health Center
Therapy /Speech Pathology Services
• Histocompatibility Laboratory
• Religious Non-Medical Health Care Institution
• Home Health Agency
• Rural Health Clinic
• Hospice
• Skilled Nursing Facility
If your provider type is not listed above, contact your designated fee-for-service contractor before you
submit this application.
Complete this application if you are a health care organization and you:
• Plan to bill Medicare for Part A medical services, or
• Would like to report a change to your existing Part A enrollment data. A change must be reported
within 90 days of the effective date of the change; per 42 C.F.R. 424.516(e), changes of ownership or
control must be reported within 30 days of the effective date of the change.
BILLING NUMBER INFORMATION
The National Provider Identifier (NPI) is the standard unique health identifier for health care providers
and is assigned by the National Plan and Provider Enumeration System (NPPES). Medicare healthcare
providers, except organ procurement organizations, must obtain an NPI prior to enrolling in
Medicare or before submitting a change to your existing Medicare enrollment information. Applying
for an NPI is a process separate from Medicare enrollment. To obtain an NPI, you may apply online at
https://NPPES.cms.hhs.gov. As an organizational health care provider, it is your responsibility to determine
if you have “subparts.” A subpart is a component of an organization that furnishes healthcare and is not
itself a legal entity. If you do have subparts, you must determine if they should obtain their own unique
NPIs. Before you complete this enrollment application, you need to make those determinations and obtain
NPI(s) accordingly.
IMPORTANT: For NPI purposes, sole proprietors and sole proprietorships are considered to be
“Type 1” providers. Organizations (e.g., corporations, partnerships) are treated as “Type 2” entities.
When reporting the NPI of a sole proprietor on this application, therefore, the individual’s Type 1
NPI should be reported; for organizations, the Type 2 NPI should be furnished.
For more information about subparts, visit to view the “Medicare
Expectations Subparts Paper.”
The Medicare Identification Number, often referred to as the CMS Certification Number (CCN) or
Medicare “legacy” number, is a generic term for any number other than the NPI that is used to identify a
Medicare provider.
CMS-855A (07/11)
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