Section 1: Reason for applying
New enrollee, reactivation, voluntary termination, change of information or revalidation, with a table of the sections each type of change requires.
CMS-20134
Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers
- Agency
- CMS
- Revision
- 12/25
- Fillable fields
- 323
- Pages
- 31
- Official source
- CMS form page
- Checked
- October 20, 2026
Form CMS-20134: Medicare Enrollment Application for MDPP Suppliers
Form CMS-20134 is the Medicare Enrollment Application for Medicare Diabetes Prevention Program (MDPP) Suppliers from the Centers for Medicare & Medicaid Services. The form says any organization that wants to furnish MDPP services submits a Medicare enrollment application to become an MDPP supplier, including organizations already enrolled in Medicare, and that it is also used to change existing enrollment information. It lists three supplier types: in-person, in-person with distance learning, and online.
The application has 17 sections, with Sections 9 to 12 reserved for future use. They cover the reason for applying, identifying information and CDC recognition status, final adverse legal actions, MDPP locations, owners and managing control, the coach roster, billing agency, contact person, penalties for falsifying information, certification signatures, delegated officials and a supporting documents checklist.
The form says the completed application, with original signatures and all required documentation, goes to the Medicare Administrative Contractor (MAC) that services the supplier's State, and notes that the online PECOS system can be used instead. You can fill it out free in your browser on this page and download the result without an account.
What's on Form CMS-20134
Section 2: Identifying information
Supplier type, legal business name as reported to the IRS, tax ID, other names, proprietary or non-profit status, organizational structure, CDC recognition status with organizational code and dates, and a correspondence address.
Sections 3 and 4: Adverse actions, locations
Final adverse legal actions such as convictions within the preceding 10 years and exclusions, revocations or suspensions; administrative locations and community settings, a special payments address and medical record storage.
Sections 5 and 6: Owners and managers
Organizations and individuals with 5 percent or more ownership, a partnership interest or managing control, with dates and any final adverse legal actions. Individuals give name, date of birth and Social Security Number.
Sections 7 and 8: Coaches and billing agency
Each coach's name, Social Security Number, date of birth and NPI with a start, change or end date, and any billing agency the supplier contracts with to prepare and submit claims.
Sections 13 to 17: Contact, signatures, documents
Contact person, penalties for falsifying information, the certification statement signed by authorized officials, optional delegated officials, and the supporting documents checklist.
Sections 9 to 12 are marked for future use and not applicable.
How to complete Form CMS-20134
- 1
Get NPIs first
The form's process says the MDPP supplier and its coaches obtain National Provider Identifiers before completing and submitting the application. It points to NPPES.cms.hhs.gov.
- 2
Choose the reason and sections
Check one reason in Section 1A. For a change of information, Section 1B lists which sections to complete for each kind of change.
- 3
Complete the applicable sections
The form says to type or print legibly, not in pencil, and to copy and complete a section for each additional entry, such as more locations, owners or coaches.
- 4
Have an authorized official sign
The form says only an authorized official signs an initial or revalidation application. Signatures are original and in ink (blue preferred); stamped, faxed or copied signatures are not accepted.
- 5
Attach the supporting documents
Section 17 lists a copy of the MDPP preliminary or full DPRP recognition certificate or letter, IRS confirmation of the tax ID where applicable, and Form CMS-588 for electronic funds transfer, among others.
- 6
Send it to the MAC
Mail the package to the MAC that services the State; the form points to CMS.gov/medicare/enrollment-renewal/providers-suppliers for addresses. It says the contractor may request fingerprints, conducts a site visit and gives its decision in writing.
Why fill Form CMS-20134 on indox
You get the real form, filled in a browser tab, with nothing standing between you and the finished PDF.
- Fill the form right in your browser, no software to install
- Free to fill and free to download, with no account
- The official blank straight from the CMS, not a copy someone retyped
- Works on a phone, tablet or computer
Where it goes, deadlines and payments
Where to send it
To the designated MAC that services the supplier's State. The form gives CMS.gov/medicare/enrollment-renewal/providers-suppliers for the mailing address and notes that PECOS can be used online instead.
Reporting changes
The form's supplier standards say changes of ownership, changes to the coach roster and final adverse legal action history are reported within 30 days, and all other changes within 90 days.
Extra documentation
The form says the fee-for-service contractor may ask for more documentation at any time during enrollment, to be provided within 30 days of the request.
Payments
The form says Medicare issues payments by electronic funds transfer. Form CMS-588 is not required if the supplier already receives payments electronically and is not changing its banking information.
Revalidation
MDPP suppliers revalidate every five years, the form says, and a revalidation application is not submitted until the contractor makes contact.
Privacy Act statement
The information goes into PECOS. Giving it, including Social Security Numbers, is voluntary, but the form says everything except sections marked optional is required to enroll as an MDPP supplier.
Related forms
CMS-588
Electronic Funds Transfer (EFT) Authorization Agreement
39 fields, 4 pages
CMS-855B
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
960 fields, 54 pages
CMS-855I
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
513 fields, 26 pages
CMS-855A
Medicare Enrollment Application - Institutional Providers
1,236 fields, 72 pages
CMS-855O
Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
174 fields, 11 pages
CMS-855S
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
1,031 fields, 39 pages
Who uses Form CMS-20134?
The form is for organizations, not for people with Medicare. It names the situations it covers.
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Questions about Form CMS-20134
Who files Form CMS-20134?
The form says any organization that wants to furnish Medicare Diabetes Prevention Program services submits it to become an MDPP supplier, including organizations already enrolled in Medicare. Enrolled MDPP suppliers also use it for changes.
Where is Form CMS-20134 sent?
The form says to send it, with original signatures and all required documentation, to the Medicare Administrative Contractor that services the supplier's State. Addresses are at CMS.gov/medicare/enrollment-renewal/providers-suppliers.
Can MDPP enrollment be done online?
The form notes that the online Provider Enrollment, Chain and Ownership System (PECOS) can also be used to apply or change MDPP enrollment information.
What documents go with the application?
Section 17 lists a copy of the MDPP preliminary or full DPRP recognition certificate or letter, IRS confirmation of the tax ID where applicable, and Form CMS-588, plus other documents if they apply, such as an IRS non-profit determination letter.
Who can sign Form CMS-20134?
The form says only an authorized official can sign the initial or revalidation application. A delegated official, named by an authorized official in Section 16, can sign changes and updates.
Do MDPP coaches need an NPI?
The form says the supplier and its coaches obtain NPIs before the application is submitted, and the Section 7 coach roster marks the NPI as required.
How soon are changes reported?
The supplier standards on the form say within 30 days for changes of ownership, coach roster changes and final adverse legal action history, and within 90 days for all other changes.