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CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

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Terminating (Dissolving) Practice and/or Retiring

Terminating Sole-Owned or Sole-Proprietor Practice and Retiring

Download CMS-855I.

  • Complete sections 1A, 2A, 13 and 15 (update addresses in 2D, 2E, 4C).

Terminating Practice ONLY (Multiple or Sole Owner[s])

Download CMS-855B.

  • Complete sections 1, 2B1, 13 and either 15 or 16 (update addresses in 2B3, 4B, 4E).

Terminating (Retiring) Physician and Nonphysician Practitioner

Download CMS-855I.

  • Complete sections 1A, 2A, 13 and 15 (update addresses in 2D, 2E, 4C).
Terminating (Dissolving) Practice and/or Retiring
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