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CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

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Adding or Terminating a Reassignment to an Established Group

Download CMS-855R.

Adding Reassignment

  • Complete sections 1, 2, 3, 4, 5, 6A and 6B.

To add a new reassignment, both the individual practitioner and the group’s Authorized or Delegated Official currently on file with the group must sign and date.

Note: If an individual is newly enrolling to the state, or making a change to individual enrollment information, complete and submit the CMS-855I and the CMS-855R, along with any required supporting documentation.

Terminating Reassignment (By Individual)

  • Complete sections 1, 2, 3, 5 and 6A.

Terminating Reassignment (By Organization)

  • Complete sections 1, 2, 3, 5 and 6B.

To terminate a reassignment, only one signature and date is required.

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