Form CMS-855R, Medicare Enrollment Application - Reassignment of Medicare Benefits Completed Form Examples and Samples
Find clear, completed examples of Form CMS-855R, the Medicare Enrollment Application for Reassignment of Medicare Benefits. Our filled-out samples and templates guide individual practitioners and groups on how to correctly complete the form.
Form CMS-855R Example: Physician Joining a Group Practice
How this form was filled:
This example shows a completed Form CMS-855R for an individual physician, Dr. Emily Carter, who is joining Summit Medical Group, P.C. and reassigning her rights to bill the Medicare program and receive Medicare payments for her services to the group. The form includes information for both the individual practitioner and the receiving organization, along with a specified effective date for the reassignment.
Information used to fill out the document:
- Individual Practitioner Name: Emily R. Carter, MD
- Practitioner NPI: 1234567890
- Practitioner Medicare Number (PTAN): EC12345
- Practitioner Social Security Number: XXX-XX-6789
- Group/Organization Legal Business Name: Summit Medical Group, P.C.
- Group/Organization Tax ID Number (EIN): 99-1234567
- Group/Organization NPI: 9876543210
- Group/Organization Medicare Number (PTAN): SMG9876
- Reassignment Effective Date: 03/01/2026
- Individual Practitioner Signature: Emily R. Carter
- Individual Practitioner Signature Date: 02/20/2026
- Authorized Official Name: David Chen
- Authorized Official Title: Chief Executive Officer
- Authorized Official Signature: David Chen
- Authorized Official Signature Date: 02/21/2026
What this filled form sample shows:
- Accurate completion of Section 2 with the individual practitioner's identifying information.
- Correctly filled out Section 3 with the legal business name and tax information of the group receiving the reassignment.
- A clearly specified reassignment effective date in Section 4.
- Properly executed signatures and dates in Section 5 from both the individual practitioner and the group's authorized official.
Form specifications and details:
| Form Number: | CMS-855R |
| Form Name: | Medicare Enrollment Application - Reassignment of Medicare Benefits |
| Revision Date: | (01/23) |
| Use Case: | Individual physician joining an existing medical group practice and reassigning billing privileges. |
Created: March 06, 2026 05:44 PM
