Physicians and Nonphysician Practitioners in Private Practice (Sole Owner or Sole Proprietor) With or Without any Reassigned Benefits

Revalidation instructions for sole proprietor using SSN or EIN:

Download CMS-855I.

• Complete Sections 1, 2, 3, 4, 6, 8, 12, 13 and 15B

Notes:

• Be sure to complete section 4, 4A, 4A3 (enter employer identification number) 4B, 4C, 4D, 4E and 4F (if applicable). 
• If reassigning benefits to NEW group, complete section 4F and 15C.
• Be sure to include supporting documents such as IRS CP 575 or 147C that displays the legal business name and EIN.

Download and complete CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement.

Instructions for sole owner using tax ID:

Download CMS-855I.

• Complete sections 1, 2, 3, 4, 6, 8, 12, 13 and 15B

Notes: 

• Be sure to complete sections 1, 2, and 3 ‒ Enter individual information (Type 1 NPI)
• Be sure to complete sections 4, 4A, 4A1, 4A2, 4B, 4C, 4D, 4E, 4F (when applicable) 6 and 8 – Enter organization information (Type 2 NPI)
• Be sure to include supporting documents such as IRS CP 575 or 147C that displays the legal business name and TIN/EIN.

Download and complete CMS-588 Electronic Funds Transfer (EFT) Authorization Agreement.

Related Content

• CMS-855I Completion Tips for Managing Employee Information in Section 6
• CMS-855I Completion Tips for Physicians and NPPs in Private Practice (Sole Owner or Sole Proprietor) Revalidation Application
• Prevent Revalidation Processing Delays
• Supporting Documentation Required for Enrollment Revalidations
• Revalidation Application Checklist

Revised 10/3/2023