Terminating (Dissolving) Practice and/or Retiring
Terminating Sole-Owned or Sole-Proprietor Practice and Retiring
Download CMS-855I.
- Complete sections 1A, 2A, 13 and 15B (update addresses in 2D, 2E, 4B 4C).
Terminating Practice ONLY (Sole Owner or Multiple Owners)
Download CMS-855B.
- Complete sections 1, 2A1, 13 and 15 (update addresses in 2A3, 2A4, 4B).
Terminating (Retiring) Physician and Nonphysician Practitioner
Download CMS-855I.
- Complete sections 1A, 2A, 2D, 4F, 13 and 15B
Revised 9/27/2023
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: