Medicare Enrollment Application Information

(* ) Red asterisk indicates a required field.

Application Details

Important Note: CMS is using its authority under Section 1135 of the Social Security Act to waive the application fee for any applications submitted on or after March 1, 2020 in response to COVID-19. Please do not submit an application fee with your application. For more information on provider enrollment flexibilities related to COVID-19, please visit the CMS website [PDF] opens new browser window

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


Select 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.

You may provide up to two email addresses on this page which will receive the payment confirmation email. Upon selecting the [Pay Now] button you will be redirected to to submit your payment. You will receive a payment confirmation email if the payment was submitted successfully.