A change of information should be submitted if you are changing, adding, or deleting information under your current tax identification number. A change must be reported within 90 days of the effective date of the change.

If you are already enrolled in Medicare and are not receiving Medicare payments via electronic funds transfer (EFT), any change to your enrollment information will require you to submit an Authorization Agreement for Electronic Funds Transfer (CMS-588 form) . All future payments will then be received via EFT.

How to Change your Medicare Information

Go to Section 1B and check all that apply to your changes; complete the required sections for those changes.

Identifying Information
Complete Sections 1, 2 (complete only those sections that are changing), 3, 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

Practice Location Information, Payment Address, and Medical Record Storage Information Complete Sections 1, 2B1, 3, 4 (complete only those sections that are changing), 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

Ownership Interest and/or Managing Control Information (Organizations)
Complete Sections 1, 2B1, 3, 5, 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

Ownership Interest and/or Managing Control Information (Individuals)
Complete Sections 1, 2B1, 3, 6, 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

Chain Home Office Information
Complete Sections 1, 2B1, 3, 7, 13, and either 15 (if you are the authorized official) or 16 (if you are the delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

Medicare Enrollment Application

A change of information includes a change in managing employee, address, telephone number, practice location, request for EFT, etc. Complete the Medicare Enrollment Application — Institutional Providers (CMS-855A) if you are a health care organization and you would like to report a change to your existing Part A enrollment data.

If a CMS-855A Medicare enrollment application has never been submitted, an entire application must be submitted.

Note: National Government Services may no longer accept change of information requests communicated by letter; all changes of information must be reported using the CMS-855A application.

Note: Ownership changes that do not qualify as change of ownerships (CHOWs), acquisitions/mergers, or consolidations should be reported here. The most common example involves stock transfers. For instance, assume that a business entity’s stock is owned by A, B, and C; A sells its stock to D. While this is an ownership change, it is generally not a formal CHOW under 42 CFR 489.18. Thus, the ownership change from A to D should be reported as a change of information —not a CHOW. If you have any questions on whether an ownership change should be reported as a CHOW versus a change of information, contact the National Government Services Customer Care or the CMS regional office .

Authorized Official(s)
Complete Sections 1, 2B1, 3, 6, 13, and 15.

Delegated Official(s) (Optional)
Complete Sections 1, 2B1, 3, 6, 13, 15, and 16.

Terminations

In order to process a termination of a Medicare number, the following steps must be taken.

• You must first contact your state representative in order to determine what their requirements are prior to contacting Medicare when terminating a number (i.e., notice of the termination in the local newspaper for three days prior to termination). Note: This requirement does not apply to federally qualified health centers.
• You must submit a CMS-855A Medicare enrollment application indicating the date of requested termination.