Enrollment application can be found on the Department of State Health 2026

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enrollment application can be found on the Department of State Health Preview on Page 1

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How to use or fill out enrollment application can be found on the Department of State Health with DocHub

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your personal information in the designated fields, including your name, address, and contact details.
  3. Provide your Medicaid number and any other required identification numbers as specified in the form.
  4. Fill out the sections regarding eligibility criteria, ensuring you meet all necessary requirements outlined in the application.
  5. Review each section carefully for accuracy before submitting. Use our platform's editing tools to make any necessary changes.
  6. Once completed, save your document and submit it electronically through our platform for processing.

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What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.
Change of Ownership (CHOW): Typically occurs when a Medicare-enrolled provider has been purchased by another organization. The previous owner (or seller) and the new owner (or buyer) must report these transactions to CMS. There are three types of CHOWs: Change of Ownership, Acquisition/Merger, and Consolidation.
Description. The Provider Transaction Access Number (PTAN) is your unique Medicare identification number. This number is assigned to providers once their enrollment has been approved. To participate in Medicare, a provider needs both an NPI and a PTAN number.
Authorized Official means an appointed official (e.g., chief executive officer, chief financial officer, general partner, chairman of the board, or direct owner) to whom the organization has granted the legal authority to enroll it in the Medicare program, to make changes or updates to the organizations status in the
The Provider Enrollment, Chain, and Ownership System (PECOS) is a web-based platform managed by the Centers for Medicare Medicaid Services (CMS) that facilitates the enrollment process for Medicare providers and suppliers.

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The 855b is used for Diabetic Education and Mass Immunization while the 855s is for Durable Medical Equipment and non-accredited drugs. What is the difference between 855b and 855s? Medicare requires a $50,000 surety bond from an authorized surety company as required in 42 C.F.R. section 424.57(d).

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