internet-based provider enrollment, chain and ownership ... · pdf fileinternet-based provider...
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Internet-based Provider Enrollment, Chain and Ownership System (PECOS)
Enrollment Example
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JOHN
DOE
123-45-6789
01/18/1974
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INTERNAL MEDICINE
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JOHN DOE 123-45-6789 INTERNAL MEDICINE NEW YORK
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YOUR MEDICAL SCHOOL NAME
2002
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01/18/1974 123-45-6789
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0123456789
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Date Begin Practicing at Location
10 Oak St.
John Doe MD
Your Town
NY
55555 4444
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10 Oak St.Your Town, NY 55555 4444
10 Oak St.Your Town, NY 55555 4444
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(123) 321-1234
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(123) 321-1234
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Date You Begin Receiving Payment at this Location
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John Doe
10 Oak StYour Town, NY 55555 44444
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John Doe
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John Doe
111222333444555
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Final Step
• Print, sign and date the two-page Certification Statement and mail it along with all requested supporting documentation to the Medicare contractor
Note: Do not mail the CMS-855 paper that can be printed from Internet-based PECOS.
Retain this information for your records.