- Determine if you Will Use PECOS or Paper to Revalidate
- Submit Revalidation Using PECOS
- Submit Revalidation Using Paper
- Clinics/Group Practices and Other Suppliers
- Physicians and Nonphysician Practitioners in Private Practice (Sole Owner or Sole Proprietor) With or Without any Reassigned Benefits
- Physicians and Nonphysician Practitioners that Reassign All Benefits
- Electronic Funds Transfer Agreement
- Supporting Documents
Physicians and Nonphysician Practitioners that Reassign All Benefits
Download CMS-855I.
- Complete Sections: 1, 2, 3, 4, 4F, 12, 13 and 15B
Note:
- Submit national board certification and diploma for nonphysician practitioners.
- If adding reassigning benefits to another group, complete section 4F and 15C.
Related Content
- CMS-855I Completion Tips for Physicians and NPPs that Reassign ALL Benefits Revalidation Application
- Prevent Revalidation Processing Delays
- Supporting Documentation Required for Enrollment Revalidations
- Revalidation Application Checklist
Revised 10/3/2023
Helpful Resources
Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee
J6 Mailing Address:
National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475
Interactive Voice Response:
877-908-9499
Contact Enrollment:
877-908-8476
Hours Available:
Monday–Friday
8:00 a.m.–4:00 p.m. CT
Form(s) you'll need:
Helpful Resources
Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee
JK Mailing Address:
National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149
Interactive Voice Response:
877-869-6504
Contact Enrollment:
888-379-3807
Hours Available:
Monday–Friday
8:00 a.m.–4:00 p.m. ET
Form(s) you'll need: