Physicians or Nonphysician Practitioners With/Without Private Practice
Download CMS-855I.
Complete the CMS-855I 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, 2A, 3 and 15B 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 private practice location when correspondence and special payment addresses are the same as the new private practice location:
1B. WHAT INFORMATION IS CHANGING?
Note: If practitioner is adding a reassignment, complete section 4F, 15B and/or C.
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Revised 9/26/2023