Adding or Terminating a Reassignment to an Established Group

Table of Contents

• Adding Reassignment
• Terminating Reassignment (By Individual)
• Terminating Reassignment (By Organization)
• Terminating Physician Assistant Employment Arrangement (by Organization)

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Download CMS-855I

Adding Reassignment

Complete sections 1A (Reporting a Change), 1B (Reassignment of Benefits), 2A, 4F, 12, 13 and 15B and C.

To add a new reassignment, both the individual practitioner and the group’s Authorized or Delegated Official currently on file must sign and date. Exception: Only need physician assistant signature and date.

Note: If an individual is newly enrolling to the state, or making other changes to individual enrollment information, complete and submit the CMS-855I version (5/23) , along with any required supporting documentation.

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Terminating Reassignment (By Individual)

• Complete sections 1A (Reporting a Change), 1B (Reassignment of Benefits), 2A, 4F, 12, 13 and 15B.

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Terminating Reassignment (By Organization)

• Complete sections 1A (Reporting a Change), 1B (Reassignment of Benefits), 2A, 4F, 12, 13 and 15C.

To terminate a reassignment, only one signature and date is required.

Download CMS-855B

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Terminating Physician Assistant Employment Arrangement (by Organization)

• Complete sections 1, 2A1, 2F, 3 and 15 or 16.

Revised 11/1/2023