Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Page 2
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5Form Approved OMB
No. 0938-1179
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Expires: 04/19
CENTERS FOR MEDICARE & MEDICAID SERVICES
WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION
Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare
payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently
established reassignment of benefits. Reassigning your Medicare benefits allows an eligible organization/group
to submit claims and receive payment for Medicare Part B services that you have provided as a member of the
organization/group. Such an eligible organization/group may be an individual, a clinic/group practice or other
health care organization.
Both the individual practitioner and the eligible organization/group must be currently enrolled (or concurrently
enrolling via submission of the CMS-855B for the eligible organization/group and the CMS-855I for the individual
practitioner) in the Medicare program before the reassignment can take effect. Generally, this application is
completed by the organization/group, signed by the Delegated/Authorized Official of the organization/group and
the individual practitioner, and submitted by the organization/group. When terminating a current reassignment,
either the organization/group or the individual practitioner may submit this application with the appropriate
sections completed and signed.
NOTE: A separate CMS-855R must be submitted for each organization/group where a reassignment is being
established or terminated.
The individual or delegated/authorized official, by his/her signature, agrees to notify the Medicare Administrative
Contractor (MAC) of any future changes to this reassignment in accordance with 42 CFR § 424.516(d)(2).
NOTE: An individual does not need to reassign their benefits to a corporation, limited liability company,
professional association, etc., when he/she is the sole owner. See the CMS-855I Application for Physicians and Non-
Physician Practitioners for more information.
NOTE: Physician Assistants: This application should not be used to report employment arrangements. Employment
arrangements must be reported using the CMS-855I application.
Physicians and non-physician practitioners, other than physician assistants, can reassign Medicare benefits or
terminate a reassignment of Medicare benefits after enrollment in the Medicare program or make a change in
their reassignment of Medicare benefit information using either:
• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or
• The paper CMS-855R application. Be sure you are using the most current version.
For additional information regarding the Medicare enrollment and reassignment process, including Internet-based
PECOS and to get the current version of the CMS-855R, go to
INSTRUCTIONS FOR COMPLETING THIS APPLICATION
• Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred.
• Sign and date the certification statement(s) as appropriate.
• Enter all NPIs in the applicable sections.
• Keep a copy of your completed Medicare reassignment package for your own records.
ADDITIONAL INFORMATION
When establishing a new reassignment, Section 6A must be signed by the individual practitioner and Section
6B must be signed by a delegated or authorized official of the organization/group. If the reassignment is to an
individual, that person must sign Section 6B. When terminating a reassignment, either Section 6A or Section
6B can be completed. Reassigned claims for services rendered by the individual will no longer be paid to the
organization/group after the effective date of the termination.
The MAC may request additional documentation to support and validate information reported on this application.
You are responsible for providing this documentation in a timely manner, usually within 30 days of the request.
The information you provide on this form is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively.
For more information, see the last page of this application to read the Privacy Act Statement.
WHERE TO MAIL YOUR APPLICATION
Send the completed application with original signatures to your designated MAC. The MAC that processed your
initial enrollment application is responsible for processing your
reassignment
application. To locate the mailing
address for your designated MAC, go to
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CMS-855R (04/16)
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