Section 1: Basic information
The reason for submitting, from new enrollment, revalidation and reactivation to a change or voluntary termination. For a change, Section 1B maps each kind of information to the sections to complete.
CMS-855I
Medicare Enrollment Application - Physicians and Non-Physician Practitioners
- Agency
- CMS
- Revision
- 05/23
- Fillable fields
- 513
- Pages
- 26
- Official source
- CMS form page
- Checked
- October 20, 2026
CMS-855I: Medicare Enrollment Application for Physicians and Non-Physician Practitioners
Form CMS-855I is the Medicare Enrollment Application for Physicians and Non-Physician Practitioners from the Centers for Medicare & Medicaid Services (CMS). The form says all physicians, and all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act, complete it to enroll in Medicare and receive a Medicare billing number. It is also used to revalidate, reactivate, report changes and add, change or end a reassignment of benefits, since the form notes that the CMS-855R has been discontinued.
After three pages of instructions, Section 1 asks why you are submitting the application and which sections to complete. The rest covers personal identifying information, final adverse legal actions, business information and practice locations, reassignment of benefits, managing employees, billing agencies, supporting documents, a contact person, penalties and signatures. Sections 5, 7, 9, 10 and 11 are intentionally left blank.
The form says the same enrollment actions can be done online through PECOS, the Internet-based Provider Enrollment, Chain and Ownership System. The paper form goes to your designated Medicare Administrative Contractor (MAC), and it says the form 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-855I
Section 2: Personal identifying information
Identity and NPI, licenses, certifications and DEA registration, new patient status, correspondence and medical record addresses, residency, and the physician or non-physician specialty with questions for certain professions.
Section 3: Final adverse legal actions
Convictions within the preceding 10 years, exclusions, revocations and suspensions, and 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: Business information
Private practice structure, legal business name and TIN, practice locations, the remittance and special payments address, medical records storage, services in patients' homes, and in 4F who receives reassigned benefits.
Sections 6 and 8: managing employees and billing agent
Section 6 lists managing employees and their final adverse legal action history. Section 8 records a billing agency or agent that prepares and submits your claims. The form says neither is needed when reassigning 100% of benefits.
Sections 12 to 15: documents and signatures
A supporting documents list, an optional contact person, the penalties for falsifying information, and the certification statement signed by the practitioner, plus 15C for an organization/group official in a reassignment.
The form says all fields are required except those marked optional, and to copy a section when more space is needed.
How to submit Form CMS-855I
- 1
Get an NPI first
The form says the NPI comes from NPPES in a separate process, and the name, SSN, legal business name and TIN on this application are the same ones used to obtain 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, 2A, 3 and 15 are always completed when reporting any information.
- 3
Fill in the sections that apply
Section 4 opens with three boxes that say which parts of it to complete, based on whether you have a private practice and whether you reassign benefits.
- 4
Gather supporting documents
Section 12 lists documents such as final adverse legal action records, CMS-460 to be a participating practitioner, CMS-588 with a voided check or bank letter, and IRS confirmation of the TIN and legal business name.
- 5
Type it and sign Section 15
The form says it is to be typed, and that only the individual practitioner can sign Section 15B. A new reassignment also has Section 15C signed by the organization/group's delegated or authorized official.
- 6
Send it to your MAC
Send the application with original signatures and all required documents to the MAC that serves your State, or make the same request through PECOS.
Why fill Form CMS-855I 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 Medicare Administrative Contractor (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 enrollment and changes, including reassignments, can be done through Internet-based PECOS, and that your current enrollment record can be viewed at PECOS.cms.hhs.gov.
Requests for more documents
The form says the MAC may request more documentation and that it is due within 30 days of the request, citing 42 C.F.R. section 424.525(a)(1) and (2).
Practice locations in other areas
Only practice locations within your MAC's jurisdiction go on this application. The form says locations outside it need a separate CMS-855I sent to the MAC with jurisdiction there.
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 an average of 0.5 to 3 hours per response, including reviewing instructions and gathering the information.
Related forms
CMS-855B
Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers
960 fields, 54 pages
CMS-460
MEDICARE PARTICIPATING PHYSICIAN OR SUPPLIER AGREEMENT
11 fields, 3 pages
CMS-588
Electronic Funds Transfer (EFT) Authorization Agreement
39 fields, 4 pages
CMS-855O
Medicare Enrollment Application - Registration For Eligible Ordering and Referring Physicians and Non-Physician Practitioners
174 fields, 11 pages
CMS-855A
Medicare Enrollment Application - Institutional Providers
1,236 fields, 72 pages
CMS-855S
Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
1,031 fields, 39 pages
Who uses Form CMS-855I?
Page 1 of the form lists who completes this application.
Official sources and the blank
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Questions about Form CMS-855I
Can I enroll online instead of filing the paper CMS-855I?
The form says physicians and non-physician practitioners can enroll or make changes, including reassignments, through Internet-based PECOS or with the paper CMS-855I. You can also fill out the PDF here free and download it.
Is the CMS-855R still used for reassignments?
No. The form says all reassignment actions are now reported on the CMS-855I and that the CMS-855R (Reassignment of Medicare Benefits) has been discontinued.
Can the CMS-855I be handwritten?
No. The instructions in the form say it is to be typed and may not be handwritten.
Which sections are needed to report a change?
Section 1B lists the sections for each kind of change, such as practice location, managing employee or billing agency. The form says sections 1, 2A, 3 and 15 are always completed in addition to the section that is changing.
Who signs Form CMS-855I?
The form says the individual practitioner is the only person who can sign, and that this authority may not be delegated. For a new reassignment, the practitioner signs Section 15B and a delegated or authorized official of the organization/group signs Section 15C.
Is an NPI needed before applying?
Yes. The form says an NPI from NPPES is obtained and reported on the application before enrolling, in a process separate from Medicare enrollment. It can be requested online at NPPES.cms.hhs.gov.
Where do I send Form CMS-855I?
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.