Provider Clinics/Group Practices and Other Suppliers
Download CMS-855B.
Complete the CMS-855B section 1A by selecting “You are reporting a change to your Medicare enrollment Information,” then in section 1B, check all that apply and complete the required sections as instructed.
When reporting ANY information, sections 1, 2A1, 3, and 15 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. WHAT INFORMATION IS CHANGING
