CMS-855R 2016 free printable template

MEDICARE ENROLLMENT APPLICATION REASSIGNMENT OF MEDICARE BENEFITS CMS-855R SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION AND FOR INFORMATION ON WHERE TO MAIL THIS COMPLETED APPLICATION. TO VIEW YOUR CURRENT MEDICARE REASSIGNMENTS GO TO HTTPS //PECOS.CMS.HHS.GOV Form Approved OMB No. 0938-1179 Expires 04/19 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES WHO SHOULD COMPLETE AND SUBMIT THIS APPLICATION Complete this application if you are...

How to fill out CMS-855R

How to fill out CMS-855R

1. Obtain the CMS-855R form from the CMS website or local Medicare office.
2. Fill in your legal business name as it appears on official documents.
3. Provide the relevant tax identification number (TIN) or Social Security number (SSN).
4. Specify your Medicare billing number and the NPI (National Provider Identifier) if applicable.
5. Indicate the changes you are reporting, such as ownership or location changes.
6. Complete the required sections including the signature and date.
7. Review the entire application for accuracy and completeness.
8. Send the completed CMS-855R form to the appropriate Medicare Administrative Contractor (MAC) for processing.

Who needs CMS-855R?

1. Providers or suppliers who need to report changes to their Medicare enrollment information.
2. Entities that have previously enrolled in Medicare but need to update their existing records.
3. Organizations that have undergone ownership changes, location changes, or changes in authorized official.

People Also Ask about

What is 855B used for?

What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.

What is the difference between 855I and 855R?

CMS-855I: For reassigning individuals who are new to the Medicare program, or not PECOS enrolled (sections 1, 2, 3, 4B, 13, and 15). CMS-855I: For employed physician assistants (sections 1, 2, 3, 13, and 15). CMS-855R: Individuals reassigning (entire application).

What is 855R reassignment of benefits?

The CMS-855R application is used by individual physicians and non-physician practitioners (hereafter collectively referred to as “individual practitioners”) who want to reassign their right to receive Medicare payments to another eligible individual or entity (i.e., sole proprietorship/clinic/group practice/other

What is an 855B form?

CMS 855B. Form Title. Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers.

What is an 855R form?

Form # CMS 855R. Form Title. Medicare Enrollment Application - Reassignment of Medicare Benefits.

What is the difference between Medicare 855B and 855s?

The 855b is used for Diabetic Education and Mass Immunization while the 855s is for Durable Medical Equipment and non-accredited drugs. What is the difference between 855b and 855s? Medicare requires a $50,000 surety bond from an authorized surety company as required in 42 C.F.R. section 424.57(d).

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What is CMS-855R?

CMS-855R is a form used by healthcare providers to report changes in their enrollment information with Medicare. It is part of the CMS-855 series of forms utilized for the enrollment of Medicare providers and suppliers.

Who is required to file CMS-855R?

Providers who have previously enrolled in Medicare and need to report changes to their enrollment information, such as changes in ownership, practice location, or other key details, are required to file CMS-855R.

How to fill out CMS-855R?

To fill out CMS-855R, providers should carefully read the instructions provided by CMS, accurately complete the required sections of the form, and ensure that all supporting documents are included before submitting it to the appropriate Medicare contractor.

What is the purpose of CMS-855R?

The purpose of CMS-855R is to allow healthcare providers to update their existing Medicare enrollment information, ensuring that the data on file is current and accurate to facilitate proper reimbursement and compliance.

What information must be reported on CMS-855R?

The CMS-855R requires providers to report various types of information, including changes in ownership, practice locations, disclosing new or existing affiliations, and updating contact information, among other key details essential for enrollment verification.