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Medicare Enrollment Application - Institutional Providers, Form CMS-855A (09/2024, OMB Exp. 09/30/2027)
Medicare Enrollment Application - Institutional Providers, Form CMS-855A (09/2024, OMB Exp. 09/30/2027) is a blank, fillable PDF (AcroForm) with 1237 fillable fields over 72 pages. It is filed under Nursing & Healthcare Support › Medicare (CMS) and relates to United States.
Made for people and organisations working in nursing & healthcare support who need the United States document in a clean, fillable form.
| Format | PDF (AcroForm) |
|---|---|
| Pages | 72 |
| Form fields | 1237 fillable fields |
| Jurisdiction | United States |
| Field / type | Nursing & Healthcare Support › Medicare (CMS) |
| Version (last updated) | 2026-10-16 |
| Licence | US-gov-PD (checked 2026-10-16) |
| Attribution | Source: U.S. Centers for Medicare & Medicaid Services, Medicare Enrollment Application - Institutional Providers, CMS-855A (09/24, OMB 0938-0685, Exp. 09/30/2027), cms.gov (U.S. Government work, 17 U.S.C. 105). Prepared by FormSphere as a fillable AcroForm; not affiliated with or endorsed by CMS, HHS or Medicare. |
Where this document comes from
| Origin | Official form published by cms.gov |
|---|---|
| Licence | US federal government work (public domain) |
| Rights checked | 2026-10-16 |
| PDF check | 1237 fillable fields over 72 pages, blank |
| Status | Preview only: licence review in progress |
What you get over the free original
- The publisher's original is free at cms.gov. We link to that source and do not replace it.
- A clean, blank AcroForm: every field empty, working in any PDF reader, with wording, page order and layout unchanged.
- Checked page by page against the source, with its licence and the date we checked it shown here.
Questions about this document
Can I fill in Medicare Enrollment Application - Institutional Providers, Form CMS-855A (09/2024, OMB Exp. 09/30/2027) without printing it?
Yes. Open the PDF in any normal PDF reader, type into the fields, tick the boxes and save. You can still print it if you prefer.
Is this document up to date and legally valid?
Please check the document for currency and for the rules that apply to you. It is a blank template, not legal advice or a guarantee of compliance.
Can I try it before buying?
A free preview of the first page is available when previews are switched on.