Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits Page 3
Download a blank fillable Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-855r - Medicare Enrollment Application - Reassignment Of Medicare Benefits with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5SECTION 1: BASIC INFORMATION
REASON FOR SUBMITTING THIS APPLICATION
Check the applicable box and complete the required sections.
You are enrolling or are currently enrolled in
Effective Date (mm/dd/yyyy):
Complete all sections
Medicare and will be reassigning your benefits
You are an individual practitioner terminating a
Effective Date (mm/dd/yyyy):
Complete sections 1, 2, 3, 5,
reassignment with an organization/group
and 6A
You are the organization/group terminating a
Effective Date (mm/dd/yyyy):
Complete sections 1, 2, 3, 5,
reassignment with an individual
and 6B
SECTION 2: ORGANIZATION/GROUP RECEIVING THE REASSIGNED BENEFITS
Organization/Group Identification
Provide the information below for the organization/group to whom benefits are being reassigned, or a
reassignment is being terminated. If the organization/group’s initial enrollment application is being submitted
concurrently with this reassignment application, write “pending” in the Medicare identification number block.
The organization/group’s name as reported to the IRS must be the same as reported on the organization/group’s
CMS-855B when it enrolled.
Organization/Group Legal Business Name (as Reported to the Internal Revenue Service)
Tax Identification Number (TIN)
Medicare Identification Number (PTAN) (if issued) National Provider Identifier (NPI)
SECTION 3: INDIVIDUAL PRACTITIONER WHO IS REASSIGNING BENEFITS
Individual Practitioner Identification
Provide the information below for the individual practitioner who will be reassigning his/her benefits, or who will
be terminating a reassignment. If the individual’s initial enrollment application is being submitted concurrently
with this reassignment application, write “pending” in the Medicare identification number block.
First Name (Print)
Middle Initial
Last Name (Print)
Jr., Sr., M.D., etc.
Social Security Number (SSN)
Medicare Identification Number (PTAN) (if issued)
National Provider Identifier (NPI)
SECTION
4:
PRIMARY
PRACTICE
LOCATION (Optional)
Primary Practice Location
Identify the primary practice location of the organization/group where the individual practitioner will render
services most of the time. This practice location must be currently enrolled or enrolling in Medicare.
Practice Location Name (“Doing Business As” Name)
Practice Location Address Line 1 (Street Name and Number)
Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town
State
ZIP Code +4
PTAN for this location (if different than PTAN reported in Section 2)
NPI for this location (if different than NPI reported in Section 2)
2
CMS-855R (04/16)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Cms-855b - Medicare Enrollment Application - Clinics/group Practices And Certain Other Suppliers
Medical
Form Cms-855i - Medicare Enrollment Application - Physicians And Non-physician Practitioners
Medical
Form Cms-855s - Medicare Enrollment Application - Durable Medical Equipment, Prosthetics, Orthotics, And Supplies (dmepos) Suppliers
Medical
Form Cms-20027 - Medicare Redetermination Request Form, Form Cms-20034 - Request For Medicare Hearing By An Administrative Law Judge Etc.
Medical
Related Categories
Parent category: Medical