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Posting Date: 09/25/2023
Adding a New Reassignment of Benefits Using the CMS-855I
Adding a New Reassignment of Benefits Using the CMS-855I Download CMS-855I version (5/23): Complete sections 1A and B, 2A, 3, 4F (add, terminate, change reassignment), 13, and 15B and 15C IMPORTANT: If an individual is new to the [...]
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Posting Date: 06/11/2019
Electronic Funds Transfer Agreement
Electronic Funds Transfer Agreement Download and complete the CMS-588 EFT Authorization Agreement. Physicians and nonphysician practitioners who are reassigning all of their payments to another entity are not required to submit the CMS-588. [...]
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Posting Date: 09/22/2023
Individual (Group Member) Reassigning Benefits Only
Individual (Group Member) Reassigning Benefits Only Download CMS-855I: Complete sections 1, 2, 3, 4, 4F, 12, 13 and 15 (B and C). Reassignment means that an individual physician, nonphysician practitioner, or other supplier has granted [...]
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Posting Date: 11/08/2019
Supporting Documents
Supporting Documents Attach required supporting documentation for individuals or organizations. Submit all applicable documents: CMS-588 EFT Authorization Agreement and voided check or bank confirmation letter IRS document(s) confirming [...]
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