Form CMS-855B PDF Details

This form must be typed. It may not be handwritten.

Tax ID change: If you are reporting a change to your current Medicare enrollment to your tax identification number, you must complete a new application.

Revalidation: Do not submit a revalidation application until you have been contacted by your MAC.

Where to send: Send this completed application with original signatures and all required documentation to your designated MAC.

NPI: Applicants using this application require a Type 2 NPI.

Documentation: The MAC may request additional documentation. You are responsible for providing this documentation within 30 days of the request.

QuestionAnswer
Form NameForm CMS-855B
Form Length54 pages
Fillable?Yes
Fillable fields965
Avg. time to fill out60+ min
Edition12/2025
Where to sendYour designated MAC
Matches the agency's fileYes, checked October 1, 2026
Other namesCMS-855B, CMS 855B, CMS855B, 855B, Form 855B, Medicare Enrollment Application, Clinics/Group Practices and Other Suppliers
Official sourceForm CMS-855B (Rev 12/2025), Centers for Medicare & Medicaid Services

Cms 855B Form isn’t the one you’re looking for?

Related Documents

  • CMS-460

    The CMS-460 must be submitted for all initial enrollments or reactivations only if you want to be a participating supplier in Medicare.

  • CMS-588

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