Form CMS-855-R Reasignment of Medicare Benefits Application

MEDICARE ENROLLMENT APPLICATION
REASSIGNMENT OF MEDICARE BENEFITS

CMS-855R
SEE PAGE 1 TO DETERMINE IF YOU ARE COMPLETING THE CORRECT APPLICATION
SEE PAGE 2 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
Expires: XX/XX

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.
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.
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 C.F.R. section 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
Non- Physician 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.
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 AND SUBMITTING THIS APPLICATION
• All information on this form is required with the exception of those fields specifically marked as “optional.”
Any field marked as optional is not required to be completed nor does it need to be updated or reported as
a “change of information” as required in 42 C.F.R. section 424.516. However, it is highly recommended that if
reported, these fields be kept up-to-date.
• Type or print all information so that it is legible. Do not use pencil.
• Ensure that the legal business name shown in Section 2 matches the name on the tax documents.
• Enter all NPIs in the applicable sections.
• Sign and date the certification statement(s) as appropriate.
• 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.
• You may visit our website to learn more about the enrollment process via the Internet-Based Provider
Enrollment Chain and Ownership System (PECOS) at: https://www.cms.gov/Medicare/Provider-Enrollment- andCertification/MedicareProviderSupEnroll/InternetbasedPECOS.html. Also, all of the CMS-855 applications are
all located on the CMS webpage: https://www.cms.gov/medicare/cms-forms/cms-forms/ cms-forms-list.html.
Simply enter “855” in the “Filter On:” box on this page and only the application forms will be displayed to
choose from.
• The MAC may request additional documentation to support and validate information reported on this
application. You are responsible for providing this documentation within 30 days of the request per 42 C.F.R.
section 424.525(a)(1).
• 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.

DEFINITIONS
NOTE: For the purposes of this CMS-855R application, the following definitions apply:
Add: You are adding additional information to your existing information (e.g. practice locations).
Change: You are replacing existing information with new information (e.g. contact person) or updating existing
information (e.g. change in suite #, telephone #).
Remove: You are removing existing information.

WHERE TO MAIL YOUR APPLICATION
Send this completed application with original signatures and all required documentation to your designated MAC.
The MAC that services your State is responsible for processing your enrollment application. To locate the mailing
address for your designated MAC, go to www.cms.gov/MedicareProviderSupEnroll.

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SECTION 1: BASIC INFORMATION
ALL APPLICANTS MUST COMPLETE THIS SECTION
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/organization
changing information on a currently existing
reassignment

Effective Date (mm/dd/yyyy):

Complete sections 1, 2 or
3, as applicable, sections 4
and/or 5, as applicable,
and section 6A or 6B, as
applicable

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/INDIVIDUAL RECEIVING THE REASSIGNED BENEFITS
A. 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)

B. Individual Identification
Provide the information below for the individual to whom benefits are being reassigned, or a reassignment
is being terminated. If the individual’s initial enrollment application is being submitted concurrently with this
reassignment application, write “pending” in the Medicare identification number block. The individual’s name as
reported to the Social Security Administration must be the same as reported on the individual’s CMS-855I when
the individual enrolled. If the individual is a sole proprietor with an Employee Identification Number (EIN), check
the appropriate box and report the EIN.
First Name (Print)

Middle Initial

Last Name (Print)

Social Security Number (SSN) (List number below if applicable)

Medicare Identification Number (PTAN) (if issued)

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

Employer Identification Number (EIN) (List number below if applicable)

National Provider Identifier (NPI)

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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 field.
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: PRACTICE LOCATION(S) (Optional)
A. 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.
If you are changing information about a currently reported primary practice location or adding or removing
primary practice location information, check the applicable box, furnish the effective date, and complete the
appropriate fields in this section.
Change  

Add  

Remove   Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town

State

Medicare Identification Number for this location – PTAN (if issued)

ZIP Code +4

National Provider Identifier (NPI)

B. Secondary Practice Location
Identify additional practice location.
If you are changing information about a currently reported an additional practice location or adding or removing
an additional practice location information, check the applicable box, furnish the effective date, and complete the
appropriate fields in this section.
Change  

Add  

Remove   Effective Date (mm/dd/yyyy):

Practice Location Name (“Doing Business As” Name)

Practice Location Street Address Line 1 (Street Name and Number – NOT a P.O. Box)

Practice Location Address Line 2 (Suite, Room, Apt. #, etc.)

City/Town

Medicare Identification Number for this location – PTAN (if issued)

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State

ZIP Code +4

National Provider Identifier (NPI)

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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.
If you are changing information about a currently reported contact person or adding or removing a contact
person, check the applicable box, furnish the effective date, and complete the appropriate fields in this section.
Change  
First Name

Add  

Remove   Effective Date (mm/dd/yyyy):
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

Telephone Number

State

Fax Number (if applicable)

ZIP Code +4

Email Address (if applicable)

NOTE: The Contact Person listed in this section will only be authorized to discuss issues concerning this or any
other enrollment application. Your designated MAC will not discuss any other Medicare issues about you with the
above Contact Person.

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SECTION 6: CERTIFICATION STATEMENTS AND SIGNATURES
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 C.F.R. section 424.73 and 42 C.F.R. section 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 or individual shown in
Section 2. 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 C.F.R. section 424.80. 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)

In order to process this application it MUST be signed and dated.

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)

In order to process this application it MUST be signed and dated.

PRA Disclosure Statement
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 (Expires XX/XXXX). 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 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, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden
approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions
or concerns regarding where to submit your documents, please visit http://www.cms.gov/MedicareProviderSupEnroll.
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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. 04–134), 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.
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 non-identifiable 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: https://www.cms.gov/Research-Statistics-Dataand-Systems/ Computer-Data-and-Systems/Privacy/Downloads/0532-PECOS.pdf.
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. 100503) amended the Privacy Act, 5 U.S.C. section 552a, to permit the government to verify information through
computer matching.
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