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, 2A1, 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, 2A1, 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

Any time a current provider or supplier is adding, deleting, or changing information under the same tax identification number, the change must be reported using the appropriate Medicare enrollment application (i.e., CMS-855 form).

CMS-855B	Groups and incorporated entities
CMS-855I	Individuals using their Social Security number or an unincorporated tax identification number

Note: National Government Services may no longer accept change of information requests communicated by telephone, on letterhead, or on a postal change of address form.

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

Note: If a hospital, ambulatory surgical center, or portable x-ray supplier is undergoing a change of ownership (CHOW) in accordance with the principles outlined in 42 CFR 489.18, the entity must submit a new application for the new ownership.

Billing Agency Information
Complete Sections 1, 2A1, 2B1, 3, 8 (complete only those sections that are changing), 13, and either 15 (if you are an authorized official) or 16 (if you are a delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

Authorized Official(s)
Complete Sections 1, 2B1, 3, 13, and either 15 (if you are an authorized official) or 16 (if you are a delegated official), and Section 6 for the signer, if the authorized or delegated official has not been established for this provider/supplier.

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