Please rate Cms 855A 09-24
This form must be typed. It may not be handwritten.
Separate applications: if the provider functions as two or more provider types, a separate enrollment application (CMS-855A) must be submitted for each type.
Sections to complete: when reporting any information, sections 1, 2B1, 3, and 15 must always be completed in addition to the information that is changing.
Change of ownership (CHOW): a CHOW typically occurs when a Medicare provider has been purchased (or leased) by another organization.
NPI: applicants using this application require a Type 2 NPI.
Revalidation: do not submit a revalidation application until you have been contacted by the Medicare Administrative Contractor (MAC).
| Question | Answer |
|---|---|
| Form Name | CMS-855A |
| Form Length | 72 pages |
| Fillable? | Yes |
| Fillable fields | 1236 |
| Avg. time to fill out | 60+ min |
| Edition | 09/24 |
| Issuing agency | Centers for Medicare & Medicaid Services |
| Where to send | Your designated Medicare Administrative Contractor (MAC) |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | CMS-855A, CMS855A, CMS 855A, 855A, Form CMS-855A, Medicare Enrollment Application for Institutional Providers |
| Official source | CMS-855A (Rev 09/24), Centers for Medicare & Medicaid Services |
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Please rate Cms 855A 09-24
