Corporate

Applications and Forms

 

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

CMS-855AExternal PDF

CMS 588External PDF

Electronic Funds Transfer (EFT)

EXHIBIT 177 (PART A Only)External PDF

Interactive Help Tool

Authorized and Delegated OfficialsPDF

Organizational Structure Application RequirementsPDF

 


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