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Internet-based Provider Enrollment, Chain and Ownership System (PECOS) Enrollment Example

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Page 1: Internet-based Provider Enrollment, Chain and Ownership

Internet-based Provider Enrollment, Chain and Ownership System (PECOS)

Enrollment Example

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X

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JOHN

DOE

123-45-6789

01/18/1974

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INTERNAL MEDICINE

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X

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JOHN DOE 123-45-6789 INTERNAL MEDICINE NEW YORK

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X

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YOUR MEDICAL SCHOOL NAME

2002

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01/18/1974 123-45-6789

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X

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X

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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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X

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X

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X

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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.


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