Medicare Enrollment Application Information

(* ) Red asterisk indicates a required field.

Application Details

Please enter all required information from the enrollment application for which you wish to submit payment.

Expected Format: 10 Digits

Expected Format: 9 digits without special characters included

* Please select the Provider/Supplier Service and Speciality Type:

* Is the applicant an Indian Health Service (IHS) facility?

* Is this provider a Tribal Owned FQHC?

* Is this a free-standing Hospice or a Hospice sub-unit?      Expandmore information on Hospice (Freestanding) Provider Type

  Expandmore information on Hospice (Sub-Unit) Provider Type


Click the [Apply] button to show the Fee-for-Service Contractors for your State and   Specialty:

Not required for Organ Procurement Organization or Part B CAP Drug Vendor provider/supplier types.

Upon clicking the [Pay Now] button you will be redirected to the payment submission page. Please provide your email address when prompted to do so during payment submission. In the event of an unexpected disconnection during the payment process, you will receive a payment confirmation email if the payment was submitted successfully.