Section 1: Basic information
The reason for submitting, from new enrollment to CHOW, acquisition/merger, consolidation or voluntary termination. For a change, Section 1B lists the sections required for each kind of information.
CMS-855A
Medicare Enrollment Application - Institutional Providers
- Agency
- CMS
- Revision
- 09/24
- Fillable fields
- 1236
- Pages
- 72
- Official source
- CMS form page
- Checked
- October 20, 2026
CMS-855A: Medicare Enrollment Application for Institutional Providers
Form CMS-855A is the Medicare Enrollment Application for Institutional Providers from the Centers for Medicare & Medicaid Services (CMS). The form says institutional providers complete it to enroll in Medicare and receive a Medicare billing number. It lists the organizations that use it, including hospitals, critical access hospitals, skilled nursing facilities, home health agencies, hospices, rural health clinics and opioid treatment programs, and says applicants need a Type 2 NPI.
The form is also used to revalidate, reactivate, enroll with another MAC, report changes, report a change of ownership (CHOW), acquisition/merger or consolidation, and voluntarily terminate enrollment. Section 1 asks why you are submitting and which sections to complete. The rest covers identifying information, final adverse legal actions, practice locations, ownership and managing control, billing agencies, opioid treatment program personnel, home health agency requirements, a contact person, penalties, the certification statement and supporting documents, plus Attachment 1 for skilled nursing facilities. Sections 7, 9, 11 and 16 are for future use.
The form says the same enrollment actions can be done online through PECOS. The paper form goes to your designated Medicare Administrative Contractor (MAC), and the form says it is to be typed, not handwritten. You can type it free in your browser on this page and download the result without an account.
What's on Form CMS-855A
Section 2: Identifying information
Provider type and hospital subgroups, legal business name, TIN, PTAN and NPI, IRS designation, licenses and certifications, correspondence and medical record addresses, accreditation, and CHOW, acquisition and consolidation details.
Section 3: Final adverse legal actions
Convictions within the preceding 10 years, exclusions, revocations and suspensions, with a table of each action, its date and who took it. The form says to report them even if records were expunged or appeals are pending.
Section 4: Practice locations
Each practice location within the MAC's jurisdiction, the remittance notices and special payments address, medical records storage, the base of operations for mobile or portable providers, and vehicle information.
Sections 5 and 6: ownership and control
Organizations and individuals with 5 percent or more direct or indirect ownership, partnership interests or managing control, with an organizational structure diagram. Section 6 also lists all managing employees.
Sections 8 to 17 and Attachment 1
Billing agency, OTP personnel, HHA capitalization and nursing registries, a contact person, penalties, the certification statement and signatures, the supporting documents list, and SNF ownership disclosures.
The form says all information is required except fields marked optional, and to copy a section when more space is needed.
How to submit Form CMS-855A
- 1
Get a Type 2 NPI first
The form says Medicare providers, except organ procurement organizations, obtain an NPI from NPPES before enrolling, and that the legal business name and TIN in Section 2B1 match the ones used for the NPI.
- 2
Pick your reason in Section 1
Check one box in Section 1A. For a change, Section 1B lists the sections to complete, and the form says sections 1, 2B1, 3 and 15 are always completed when reporting any information.
- 3
Fill in the sections that apply
Complete the sections Section 1 names. The form says skilled nursing facilities report ownership in Attachment 1 instead of Sections 5 and 6, and HHAs complete Section 12.
- 4
Pay the application fee
The form says to pay the required application fee through PECOS before submitting, upon initial enrollment, the addition of a new practice location and revalidation. It does not state the amount.
- 5
Gather supporting documents
Section 17 lists documents such as licenses and certifications, IRS confirmation of the TIN and legal business name, Form CMS-588 with a voided check or bank letter, bills of sale and an organizational structure diagram.
- 6
Sign Section 15 and send it
The form says only an authorized official signs the initial application. Send it with original signatures and all required documents to the MAC that serves your state, or apply through PECOS.
Why fill Form CMS-855A 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, timing and help
Where to send it
To your designated MAC, the one that services your state. The form points to CMS.gov/Medicare/Provider-Enrollment-and-Certification for the MAC's mailing address.
Online instead
The form says institutional providers can enroll or change their enrollment information through Internet-based PECOS or with the paper CMS-855A.
Approval process
The form describes the usual process: the MAC reviews the application and makes a recommendation, the State agency or an approved accreditation organization conducts a survey, the MAC may review again, and CMS makes the final decision.
Requests for more documents
The form says the MAC may request more documentation at any time during enrollment, due within 30 days of the request, citing 42 C.F.R. section 424.525(a)(1).
Penalties
Section 14 lists criminal and civil penalties for deliberately furnishing false information, citing laws such as 18 U.S.C. section 1001, section 1128B(a)(1) of the Social Security Act and the Civil False Claims Act.
Time to complete
The form estimates 6 hours per response, including reviewing instructions, searching data resources and gathering the data.
Related forms
CMS-855B
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
960 fields, 54 pages
CMS-588
Electronic Funds Transfer (EFT) Authorization Agreement
39 fields, 4 pages
CMS-855I
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
513 fields, 26 pages
CMS-855S
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
1,031 fields, 39 pages
CMS-855O
Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
174 fields, 11 pages
Who uses Form CMS-855A?
Pages 1 and 2 of the form list who completes this application.
Official sources and the blank
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Questions about Form CMS-855A
Which providers use Form CMS-855A?
The form lists community mental health centers, CORFs, critical access hospitals, ESRD facilities, FQHCs, histocompatibility laboratories, HHAs, hospices, hospitals, IHS facilities, OTPs, OPOs, outpatient therapy and speech pathology providers, RNHCIs, rural emergency hospitals, rural health clinics and SNFs.
Can I enroll online instead of filing the paper CMS-855A?
The form says institutional providers can apply for enrollment or make changes through Internet-based PECOS or with the paper CMS-855A. You can also fill out the PDF here free and download it.
Can the CMS-855A be handwritten?
No. The instructions in the form say it is to be typed and may not be handwritten.
Is there an application fee?
The form says the required application fee is paid through PECOS upon initial enrollment, the addition of a new practice location and revalidation, before the application is submitted to the MAC. It does not state the amount.
What is the difference between a CHOW, an acquisition/merger and a consolidation?
The form says in a CHOW the seller's provider number typically transfers to the new owner, in an acquisition/merger only the purchaser's Medicare and tax numbers remain, and in a consolidation a new entity gets a new TIN and Medicare Identification Number.
Does a provider with two provider types file one application?
No. The form says a provider that functions as two provider types, such as a hospital and an ESRD facility, submits a separate CMS-855A for each. A hospital with a swing-bed unit needs only one.
Who signs Form CMS-855A?
The form says only an authorized official can sign the initial application and add or remove authorized and delegated officials. Once delegation is set up, either one can sign later submissions.
Where do I send Form CMS-855A?
To your designated MAC. The form says the MAC that services your state processes the application, and points to CMS.gov/Medicare/Provider-Enrollment-and-Certification for its mailing address.