Report a Change of Information
Report change of enrollment information timely. Changes can be either submit electronic via PECOS or by the paper CMS-855A and/or CMS-588 EFT agreement.
A change in the Tax ID with no ownership change will need to submit an initial enrollment for approval.
An ownership change (CHOW, merger/acquisition or consolidation) will need to submit an application for each entity involved, follow instructions on the CMS-855A for the situation.
A change in electronic funds transfer or bank information may be the only change required or it could be in addition to another change as indicated above, for assistance completing the CMS-588 EFT form, see Electronic Funds Transfer Form and Instructions.
PECOS Submission
Instructions for accessing and submitting existing enrollment information in PECOS:
- Login to PECOS
- Select My Associates
- Scroll down under Existing Enrollment
- Select “View Enrollment” for applicable enrollment
- Select applicable enrollment record under Existing Enrollments
- Select More Options
- Select change of information and answer questionnaire(s)
- Confirm reason for application
- Select “Start Application”
- Review and update appropriate “Topic View” section(s), which may include the following topics:
- Mailing Address
- Business/Physical Location and Special Payment Address
- Organizational or Individual Control
- Contact Person
- Electronic Funds Transfer
- Upload supporting documents (if applicable)
- Resolve all errors and verify warnings
- Select “Begin Submission”
- Proceed with the Electronic Signature or Upload Certification Process
- Review and agree to Medicare regulations (Read and answer Attestation questions, if applicable)
- Verify National Government Services as your contractor
- Complete Submission button must be clicked to finish application
- Print and/or save your submission confirmation and tracking number
Related Content
Paper Submission
Download CMS-855A.
Complete the CMS-855A section 1A by selecting “You are changing your Medicare Information,” then in section 1B, check all that apply and complete the required sections as instructed.
When reporting ANY information, sections 1, 2B1, 3 and 15/16 MUST always be completed in addition to the information that is changing within the required section.
Note: Along with your application(s), submit the required supporting documentation to process the requested changes.
Example: Change in Practice Location when correspondence and special payment addresses are the same as the new practice location:
1B. Check all that apply and complete the required sections:
After the change has been submitted refer to the Provider Enrollment Application Process Timeline.
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Revised 11/23/2021