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Get CMS-855R 2020-2024

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 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 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 NonPhysician 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 http //www. cms. gov/MedicareProviderSupEnroll* INSTRUCTIONS FOR COMPLETING THIS APPLICATION Type or print all information so that it is legible.

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