Cms-855r

MEDICARE ENROLLMENT APPLICATION

REASSIGNMENT OF MEDICARE BENEFITS

CMS-855R

SEE PAGE 1 FOR INFORMATION ON WHERE TO MAIL THIS APPLICATION.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB NO. 0938-0685

GENERAL INFORMATION
Complete this application if you are reassigning your right to bill the Medicare program and receive
Medicare payments, or are terminating a reassignment of benefits. Reassigning your Medicare benefits
allows an eligible supplier to submit claims and receive payment for Medicare Part B services that you
have provided. Such an eligible supplier may be an individual, a group practice or other organization.
Both the individual practitioner and the eligible supplier must be currently enrolled (or concurrently
enrolling via submission of the CMS-855B for the eligible supplier and the CMS-855I for the practitioner)
in the Medicare program before the reassignment can take effect. Generally, this application is completed
by a supplier, signed by the individual practitioner, and submitted by the supplier. When terminating a
current reassignment, either the supplier or the individual practitioner may submit this application with the
appropriate sections completed.
The individual or authorized/delegated official, by his/her signature, agrees to notify the Medicare fee-for-serv­
ice contractor of any future changes to the reassignment within 90 days of the effective date of the change.
NOTE: An individual will not need to reassign benefits to a corporation, limited liability company,
professional association, etc., of which he/she is the sole owner. See the CMS-855I Application for
Physicians and Non-Physician Practitioners for more information.
INSTRUCTIONS FOR COMPLETING AND SUBMITTING THIS APPLICATION

• Type or print all information so that it is legible. Do not use pencil.
• Sign and date the certification statement.
• Keep a copy of your completed Medicare enrollment package for your own records and for updating
your information.
• Send the completed application with original signatures and all required documentation to your
designated Medicare fee-for-service contractor.
ADDITIONAL INFORMATION

The information you provide on this form will not be shared. It is considered to be protected under 5 U.S.C.
Section 552(b)(4) and/or (b)(6), respectively. For more information, see the Privacy Act Statement located at
the end of this application.
For additional information regarding the Medicare enrollment process, visit
www.cms.hhs.gov/MedicareProviderSupEnroll.
The Medicare Identification Number is a generic term for any number other than the National Provider
Identifier (NPI) that is used by a supplier to bill the Medicare program.
The NPI is the standard unique health identifier for health care providers and is assigned by the National
Plan and Provider Enumeration System (NPPES). As a Medicare health care supplier, you must obtain an
NPI prior to enrolling in Medicare or before submitting a change to your existing Medicare enrollment
information. Applying for the NPI is a process separate from Medicare enrollment. To obtain an NPI, you
may apply online at https://NPPES.cms.hhs.gov. For more information regarding NPI enumeration, visit
www.cms.hhs.gov/NationalProvIdentStand.
MAIL YOUR APPLICATION

The Medicare fee-for-service contractor that services your State is responsible for processing your enrollment
application. If you do not know who your fee-for-service contractor is, locate it on the CMS web site at
www.cms.hhs.gov/MedicareProviderSupEnroll.
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SECTION 1: BASIC INFORMATION

Complete this application when any of the following occur:
ADDING A NEW REASSIGNMENT

If you are:
• Enrolling for the first time in the Medicare program (and have completed the CMS-855I),

and are reassigning your benefits to an eligible supplier.

• Currently enrolled in the Medicare program and are reassigning your benefits to an

eligible supplier.

NOTE: The supplier must be enrolled or currently enrolling in Medicare (submitting the CMS-855B)
before the reassignment can take effect.
TERMINATING A CURRENT REASSIGNMENT

If you are an:
• Individual practitioner who is terminating a reassignment of benefits to the supplier identified in
Section 2. No reassigned claims will be paid to the supplier for services rendered by the practitioner
after the effective date of deletion.
• Organization that is terminating a reassignment of benefits from the individual practitioner identified in
Section 3. No reassigned claims will be paid to the supplier for services rendered by the practitioner
after the effective date of deletion.
NOTE: When adding a reassignment, Section 4A must be completed by the individual practitioner and
Section 4B must be completed by an authorized or delegated official of the supplier. (If the
supplier is an individual, that person must sign Section 4B.) When terminating a reassignment,
either Section 4A must be completed by the individual practitioner or Section 4B must be
completed by an authorized or delegated official of the supplier.

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SECTION 1: BASIC INFORMATION
ALL APPLICANTS MUST COMPLETE THIS SECTION

•Check the applicable box and complete the required sections
REASON FOR APPLICATION

❏ You are enrolling or are currently
enrolled in Medicare and will be
reassigning your benefits to this
supplier for the first time

PROVIDE INFORMATION

REQUIRED SECTIONS
A.

Effective Date (mm/dd/yyyy):
Complete all sections

Effective Date (mm/dd/yyyy):
❏ You are an individual practitioner
terminating a reassignment

Sections 1, 2, 3, and 4A

Effective Date (mm/dd/yyyy):
❏ You are an organization
terminating a reassignment

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Sections 1, 2, 3, and 4B

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SECTION 2: ORGANIZATION RECEIVING THE REASSIGNED BENEFITS

Organization/Group Identification
Provide the requested information below for the supplier to whom benefits are being reassigned, or reassignment
is being terminated. If the supplier’s initial enrollment application is being submitted concurrently with this
reassignment application, write “pending” in the Medicare identification number block.
The supplier’s name as reported to the IRS must be the same as reported on the supplier’s CMS-855B when
it enrolled.
Supplier’s Legal Business Name (as reported to the Internal Revenue Service)
Tax Identification Number

Medicare Identification Number (if issued)

National Provider Identifier

SECTION 3: INDIVIDUAL PRACTITIONER WHO IS REASSIGNING BENEFITS

Individual Practitioner Identification
Provide the information below for the individual who will be reassigning his/her benefits to this
supplier, or who will be terminating such a reassignment. If your initial enrollment application is being
submitted concurrently with this reassignment application, write “pending” in the Medicare identification
number block.
First Name
Social Security Number

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Middle Initial

Last Name

Medicare Identification Number (if issued)

Jr., Sr., etc. M.D., D.O., etc.
National Provider Identifier

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SECTION 4: AUTHORIZATION STATEMENTS

The signatures below authorize the reassignment of benefits to a supplier or the termination of a reassignment
of benefits to a supplier, as indicated in Section 1.
Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner
to be paid to another individual or supplier unless the individual practitioner who provided the services
specifically authorizes another individual or supplier (employer, facility, or health care delivery system) to
receive said payments in accordance with 42 CFR 424.73 and 42 CFR 424.80. By signing this Reassignment
of Benefits Statement, you are authorizing the supplier identified in Section 2 to receive Medicare payments
on your behalf.
Your employment or contract with this individual or supplier must be in compliance with CMS regulations
and you must be in compliance with applicable Medicare program safeguard standards described in 42
CFR 424.80. All individual practitioners who allow another supplier (employer, facility, or health care
delivery system) to receive payment for their services must sign the Reassignment of Benefits Statement.
The signatures below acknowledge that you will abide by all laws and regulations pertaining to the
reassignment of benefits.
A. Individual Practitioner
I certify that I have examined the above information and that it is true, accurate and complete. I
understand that any misrepresentation or concealment of any information requested in this application
may subject me to liability under civil and criminal laws.
Individual Practitioner First Name Middle Initial
PRINT

Last Name

Individual Practitioner Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
SIGNED

Jr., Sr., etc. M.D., D.O., etc.
Date (mm/dd/yyyy)

B. Authorized or Delegated Official
I certify that I have examined the above information and that it is true, accurate and complete. I
understand that any misrepresentation or concealment of any information requested in this application
may subject me to liability under civil and criminal laws.
First Name
PRINT

Middle Initial

Last Name

Authorized or Delegated Official’s Signature (First, Middle, Last Name, Jr., Sr., M.D., D.O., etc.)
SIGNED

Jr., Sr., etc. M.D., D.O., etc.
Date (mm/dd/yyyy)

All signatures must be original and signed in ink. Applications with signatures deemed not
original will not be processed. Stamped, faxed or copied signatures will not be accepted.

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SECTION 5: FOR FUTURE USE

(This Section Not Applicable)

SECTION 6: FOR FUTURE USE

(This Section Not Applicable)

SECTION 7: CONTACT PERSON

This section captures information regarding the person you would like for us to contact regarding this
application.
First Name

Middle Initial

Last Name

Jr., Sr., etc. M.D., D.O., etc.

Address Line 1 (Street Name and Number)
Address Line 2 (Suite, Room, etc.))
City/Town

State

Zip Code +4

Email Address (if available)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0685. The time required to complete this information collection is estimated to
average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.
DO NOT MAIL APPLICATIONS TO THIS ADDRESS. Mailing your application to this address will significantly delay application processing.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

MEDICARE SUPPLIER ENROLLMENT APPLICATION

PRIVACY ACT STATEMENT

The Centers for Medicare and Medicaid Services (CMS) is authorized to collect the information requested on this form by sections
1124(a)(1), 1124A(a)(3), 1128, 1814, 1815, 1833(e), and 1842(r) of the Social Security Act [42 U.S.C. §§ 1320a-3(a)(1), 1320a-7,
1395f, 1395g, 1395(l)(e), and 1395u(r)] and section 31001(1) of the Debt Collection Improvement Act [31 U.S.C. § 7701(c)].
The purpose of collecting this information is to determine or verify the eligibility of individuals and organizations to enroll in
the Medicare program as suppliers of goods and services to Medicare beneficiaries and to assist in the administration of the
Medicare program. This information will also be used to ensure that no payments will be made to providers who are excluded
from participation in the Medicare program. All information on this form is required, with the exception of those sections
marked as “optional” on the form. Without this information, the ability to make payments will be delayed or denied.
The information collected will be entered into the Provider Enrollment, Chain and Ownership System (PECOS) and system
number 09-70-0525 titled Unique Physician/Practitioner Identification Number (UPIN) System (published in Vol. 61 of the
Federal Register at page 20,528 (May 7, 1996)). The information in this application will be disclosed according to the routine
uses described below.
Information from these systems may be disclosed under specific circumstances to:
1. CMS contractors to carry out Medicare functions, collating or analyzing data, or to detect fraud or abuse;
2. A congressional office from the record of an individual health care provider in response to an inquiry from the

congressional office at the written request of that individual health care practitioner;

3. The Railroad Retirement Board to administer provisions of the Railroad Retirement or Social Security Acts;
4. Peer Review Organizations in connection with the review of claims, or in connection with studies or other review activities,
conducted pursuant to Part B of Title XVIII of the Social Security Act;
5. To the Department of Justice or an adjudicative body when the agency, an agency employee, or the United States

Government is a party to litigation and the use of the information is compatible with the purpose for which the agency

collected the information;

6. To the Department of Justice for investigating and prosecuting violations of the Social Security Act, to which criminal

penalties are attached;

7. To the American Medical Association (AMA), for the purpose of attempting to identify medical doctors when the Unique
Physician Identification Number Registry is unable to establish identity after matching contractor submitted data to the
data extract provided by the AMA;
8. An individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or
disability, or to the restoration or maintenance of health;
9. Other Federal agencies that administer a Federal health care benefit program to enumerate/enroll providers of medical

services or to detect fraud or abuse;

10. State Licensing Boards for review of unethical practices or non-professional conduct;
11. States for the purpose of administration of health care programs; and/or
12. Insurance companies, self insurers, health maintenance organizations, multiple employer trusts, and other health care

groups providing health care claims processing, when a link to Medicare or Medicaid claims is established, and data are

used solely to process supplier’s health care claims.

The enrolling supplier should be aware that the Computer Matching and Privacy Protection Act of 1988 (P.L. 100-503) amended
the Privacy Act, 5 U.S.C. § 552a, to permit the government to verify information through computer matching.
Protection of Proprietary Information
Privileged or confidential commercial or financial information collected in this form is protected from public disclosure by
Federal law 5 U.S.C. § 552(b)(4) and Executive Order 12600.
Protection of Confidential Commercial and/or Sensitive Personal Information
If any information within this application (or attachments thereto) constitutes a trade secret or privileged or confidential information
(as such terms are interpreted under the Freedom of Information Act and applicable case law), or is of a highly sensitive personal
nature such that disclosure would constitute a clearly unwarranted invasion of the personal privacy of one or more persons, then
such information will be protected from release by CMS under 5 U.S.C. §§ 552(b)(4) and/or (b)(6), respectively.

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