Form · Enrollment
CMS-855I form (Medicare enrollment for physicians and practitioners)
What it is, who uses it, and field-by-field help. Publisher: CMS. Links checked October 23, 2026.
Quick answer
The CMS-855I is the Medicare enrollment application for physicians and non-physician practitioners (OMB 0938-1355). You use it, or PECOS online, to enroll, revalidate, report changes, and reassign benefits to a group. It goes to your Medicare Administrative Contractor (MAC). You need an NPI first.
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At a glance
- Form
- CMS-855I, Medicare Enrollment Application: Physicians and Non-Physician Practitioners
- OMB number
- 0938-1355
- Online option
- PECOS
- Send to
- Your designated MAC, with original signatures
- Note
- Reassignment is now reported on the 855I; CMS discontinued the CMS-855R
- Get the form
- CMS-855I (PDF)
Who uses it
- Physicians and eligible professionals enrolling to bill Medicare
- Practitioners revalidating, reactivating, or adding a practice location or MAC jurisdiction
- Practitioners reassigning, or ending a reassignment of, Medicare benefits to a group
Sections
- Section 1. Basic information
- Why you are submitting: new enrollment, revalidation, reactivation, change, reassignment, or voluntary termination.
- Section 2. Personal identifying information
- Name, SSN, birth date, NPI, licenses and certifications, and specialty. The name and SSN must match your NPPES record.
- Section 3. Final adverse legal actions
- Any convictions, exclusions, license revocations, or other final adverse actions.
- Section 4. Business information
- Your practice locations, where you keep records, and other business details.
- Section 6. Managing employee
- Anyone who manages day-to-day operations for you.
- Section 8. Billing agency
- A billing company that submits claims for you, if any.
- Section 12. Supporting documentation
- Required attachments, such as the EFT authorization (CMS-588) with a voided check or bank letter.
- Section 13. Contact person
- Optional contact for questions about the application.
- Section 15. Certification statement and signature
- Your signature. A new reassignment needs 15B signed by the practitioner and 15C by the group's authorized or delegated official.
Related pages
Questions
Can I fill out the CMS-855I by hand?
No. CMS says the form must be typed.
Do I need an NPI before the CMS-855I?
Yes. The NPI comes from NPPES in a separate process, and your name and SSN must match there and in PECOS.
855I or 855B?
The 855I is for individual practitioners. Groups, clinics, and other suppliers use the CMS-855B.