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CHANGE EXISTING PROVIDER ENROLLMENT INFORMATION

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Terminating a Physician Assistant Employment Arrangement

Terminating (by PA, Sole Owner or Sole Proprietor)

Download CMS-855I (CMS-855R not needed) 

    • Complete sections 1, 2A, 2I, 3, 13 and 15.

Terminating (by Group)

Download CMS-855B (CMS-855R not needed)

    • Complete sections 1, 2, 2G, 3 and 15 or 16.
Terminating a Physician Assistant Employment Arrangement
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