Form CMS-855-R Reasignment of Medicare Benefits Application

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MEDICARE ENROLLMENT APPLICATION

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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

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

Form Approved

OMB No. 0938-1179

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).

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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.

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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.

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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. 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.

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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 www.cms.gov/MedicareProviderSupEnroll.
CMS-855R (XX/XX)

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SECTION 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
Medicare and will be reassigning your benefits

Effective Date (mm/dd/yyyy):

Complete all sections

You are an individual practitioner terminating a
reassignment with an organization/group

Effective Date (mm/dd/yyyy):

Complete sections 1, 2, 3, 5,
and 6A

You are the organization/group terminating a
reassignment with an individual

Effective Date (mm/dd/yyyy):

Complete sections 1, 2, 3, 5,
and 6B

SECTION 2: ORGANIZATION/GROUP RECEIVING THE REASSIGNED BENEFITS

Organization/Group Identification

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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)

Medicare Identification Number (PTAN) (if issued) National Provider Identifier (NPI)

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Tax Identification Number (TIN)

SECTION 3: INDIVIDUAL PRACTITIONER WHO IS REASSIGNING BENEFITS

Individual Practitioner Identification

First Name (Print)

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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.
Middle Initial

Medicare Identification Number (PTAN) (if issued)

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Social Security Number (SSN)

Last Name (Print)

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

PTAN for this location (if different than PTAN reported in Section 2)

CMS-855R (XX/XX)

ZIP Code +4

NPI for this location (if different than NPI reported in Section 2)

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SECTION 5: CONTACT PERSON INFORMATION (Optional)
If questions arise during the processing of this reassignment, the designated MAC will contact the individual
indicated below. If a contact person is not furnished, the MAC will contact the individual practitioner is Section 3.
First Name

Middle Initial

Last Name

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

Contact Person Address Line 1 (Street Name And Number)
Contact Person Address Line 2 (Suite, Room, Apt. #, etc.)
City/Town

State

Telephone Number

Fax Number (if applicable)

ZIP Code +4
Email Address (if applicable)

Relationship or Affiliation to Individual or Organization/Group (Spouse, Secretary, Attorney, Billing Agent, etc.)

NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this
reassignment. The designated MAC will not discuss any other Medicare issues about the organization/group or
individual practitioner beyond this reassignment application with the above Contact Person.

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SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES

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Title XVIII of the Social Security Act prohibits payment for services provided by an individual practitioner to be
paid to another individual or organization/group unless the individual practitioner who provided the services
specifically authorizes another individual or organization/group to receive said payments in accordance with
42 CFR § 424.73 and 42 CFR § 424.80. All individual practitioners who allow another individual or organization/
group to receive payment for their services must sign the Reassignment of Medicare Benefits Statement below.
By signing this Reassignment of Medicare Benefits Statement, you are authorizing the organization/group or
individual identified in Section 2 to receive Medicare payments on your behalf.
The signature(s) below authorize the reassignment of benefits, or the termination of a reassignment of benefits,
between the individual practitioner shown in Section 3 and the organization/group shown in Section 2.

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The employment of, or contract between, the individual practitioner and organization/group or individual must
be in compliance with CMS regulations and applicable Medicare program safeguard standards described in
42 CFR § 424.80.

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These signatures also serve as an attestation and acknowledgment to the compliance with all laws and regulations
pertaining to the reassignment of Medicare benefits.

A. Individual Practitioner Certification Statement and Signature

Under penalty of perjury, I, the undersigned, certify that the above information 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 (Print)

Middle Initial

Last Name (Print)

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

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

B. Delegated or Authorized Official of Organization/Group Certification Statement and Signature

Under penalty of perjury, I, the undersigned, certify that the above information is true, accurate and complete.
I understand that any misrepresentation or concealment of any information requested in this application may
subject me and/or the organization/group to liability under civil and criminal laws.
Delegated or Authorized Official’s First Name (Print) Middle Initial

Last Name (Print)

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

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

All signatures must be original and signed in blue ink. Applications with signatures deemed not original or not dated will not be processed.

Stamped, faxed or copied signatures will not be accepted.

CMS-855R (XX/XX)

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

MEDICARE SUPPLIER ENROLLMENT APPLICATION PRIVACY ACT STATEMENT

The Authority for maintenance of the system is given under provisions of sections 1102(a) (Title 42 U.S.C. 1302(a)),
1128 (42 U.S.C. 1320a–7), 1814(a)) (42 U.S.C. 1395f(a)(1), 1815(a) (42 U.S.C. 1395g(a)), 1833(e) (42 U.S.C. 1395I(3)), 1871
(42 U.S.C. 1395hh), and 1886(d)(5)(F), (42 U.S.C. 1395ww(d)(5)(F) of the Social Security Act; 1842(r) (42 U.S.C. 1395u(r));
section 1124(a)(1) (42 U.S.C. 1320a–3(a)(1), and 1124A (42 U.S.C. 1320a–3a), section 4313, as amended, of the BBA of
1997; and section 31001(i) (31 U.S.C. 7701) of the DCIA (Pub. L. 104–134), as amended.
The information collected here will be entered into the Provider Enrollment, Chain and Ownership System (PECOS).
PECOS will collect information provided by an applicant related to identity, qualifications, practice locations, ownership,
billing agency information, reassignment of benefits, electronic funds transfer, the NPI and related organizations. PECOS
will also maintain information on business owners, chain home offices and provider/chain associations, managing/
directing employees, partners, authorized and delegated officials, supervising physicians of the supplier, ambulance
vehicle information, and/or interpreting physicians and related technicians. This system of records will contain the
names, social security numbers (SSN), date of birth (DOB), and employer identification numbers (EIN) and NPI’s for
each disclosing entity, owners with 5 percent or more ownership or control interest, as well as managing/directing
employees. Managing/directing employees include general manager, business managers, administrators, directors,
and other individuals who exercise operational or managerial control over the provider/ supplier. The system will also
contain Medicare identification numbers (i.e., CCN, PTAN and the NPI), demographic data, professional data, past and
present history as well as information regarding any adverse legal actions such as exclusions, sanctions, and felonious
behavior.

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The Privacy Act permits CMS to disclose information without an individual’s consent if the information is to be used for
a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure of data
is known as a “routine use.” The CMS will only release PECOS information that can be associated with an individual
as provided for under Section III “Proposed Routine Use Disclosures of Data in the System.” Both identifiable and nonidentifiable data may be disclosed under a routine use. CMS will only collect the minimum personal data necessary to
achieve the purpose of PECOS. Below is an abbreviated summary of the six routine uses. To view the routine uses in
their entirety go to: http://www.cms.gov/Regulations-and-Guidance/Guidance/PrivacyActSystemofRecords/
Systems-of-Records-Items/CMS023307.html.

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1. To support CMS contractors, consultants, or grantees, who have been engaged by CMS to assist in the performance
of a service related to this collection and who need to have access to the records in order to perform the activity.
2. To assist another Federal or state agency, agency of a state government or its fiscal agent to:
a. Contribute to the accuracy of CMS’s proper payment of Medicare benefits,
b. Enable such agency to administer a Federal health benefits program that implements a health benefits program
funded in whole or in part with federal funds, and/or
c. Evaluate and monitor the quality of home health care and contribute to the accuracy of health insurance
operations.
3. To assist an individual or organization for research, evaluation or epidemiological projects related to the prevention
of disease or disability, or the restoration or maintenance of health, and for payment related projects.
4. To support the Department of Justice (DOJ), court or adjudicatory body when:
a. The agency or any component thereof, or
b. Any employee of the agency in his or her official capacity, or
c. Any employee of the agency in his or her individual capacity where the DOJ has agreed to represent the
employee, or
d. The United States Government, is a party to litigation and that the use of such records by the DOJ, court or
adjudicatory body is compatible with the purpose for which CMS collected the records.
5. To assist a CMS contractor that assists in the administration of a CMS administered health benefits program, or to
combat fraud, waste, or abuse in such program.
6. To assist another Federal agency to investigate potential fraud, waste, or abuse in, a health benefits program funded
in whole or in part by Federal funds.
The applicant 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.

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 0938-1179. 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.
CMS-855R (XX/XX)

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