Provider Enrollment

J1 Part A Provider Enrollment - CMS Provider Enrollment Application: CMS 855A

Please send your completed applications to:
 

J1 MAC - Palmetto GBA
PO Box 1508
Augusta, GA 30903-1508

Fax: 803-462-3919

J1 Part B Provider Enrollment

 

The Provider Enrollment Staff at Palmetto GBA is here to help you:

 

• Enroll in Medicare as a new provider
• Change your Medicare information, such as address or telephone changes, opening or closing offices, and changes in authorized personnel or other important information
• Add new members to your provider group
• Delete previous members of your provider group
• Set up Electronic Funds Transfer
• Change the address to which we mail your Medicare checks (AKA, Pay To Address)
• Call our Provider Enrollment staff at 1-866-931-3901 if we can help

 

To enroll in Medicare as a provider or make changes to your existing Medicare information, you must complete a CMS-855 application. There are different applications to fit different situations:

 

If you are…	Use this form:
A provider group (new, or change of existing information)	CMS 855B--Application for Health Care Suppliers that will Bill Medicare Carriers. Download this form from the CMS Web site at: http://www.cms.hhs.gov/cmsforms/downloads/cms855b.pdf
An individual provider (new, or change of existing information)	CMS 855I --Application for Individual Health Care Practitioners. Download this form from the CMS Web site at: http://www.cms.hhs.gov/cmsforms/downloads/cms855i.pdf
An individual provider joining a group or changing a group, to have payments go to the group	CMS 855R--Application for Individual Health Care Practitioners to Reassign Medicare Benefits. This form is used if you are a member of a group and want to reassign your benefits to the group. Download this form from the CMS Web site at: http://www.cms.hhs.gov/cmsforms/downloads/cms855r.pdf

 

Send your completed application, including original signatures, to:
J1 MAC – Palmetto GBA
PO Box 1508
Augusta, GA 30903-1508

Time frames:

 

You can help speed up the time it takes us to process your application by submitting complete, accurate information the first time. Please do the following when submitting your application:

 

• Include a copy of all applicable state licenses
• Check all applicable boxes and provide effective dates where needed
• Include a copy of IRS documentation as proof of Tax Identification Number (i.e., CP-575 or any legal document from the IRS showing the name and TIN)
• Sign and date all applications. Original signatures are required on each application

 

Note: Failure to provide all of the necessary information and/or documentation may cause your application to be returned to you for completion.