Form CMS-855R, Medicare Enrollment Application - Reassignment of Medicare Benefits Instructions

Enter the city or town name for the contact person's address.

Enter the state for the contact person's address.

Enter the ZIP Code, including the +4 extension if applicable, for the contact person's address.

Enter the telephone number of the contact person.

Enter the fax number of the contact person, if applicable.

Enter the email address of the contact person, if applicable.

Provide the street name and number for the contact person's address line 1.

Provide additional address details such as suite, room, or apartment number for the contact person.

Enter the first name of the contact person.

Enter the middle initial of the contact person.

Enter the last name of the contact person.

Enter any suffix or title for the contact person, such as Jr., Sr., M.D., etc.

Enter the date the individual practitioner signed the certification statement. Fill only if 'You are an individual practitioner terminating a reassignment with an organization/group' is 'Yes'.

Provide the date when the delegated or authorized official signed the certification statement. Fill only if 'Reason for submitting this application' is 'You are the organization/group terminating a reassignment with an individual'.

Provide the first name of the delegated or authorized official. Fill only if 'Reason for submitting this application' is 'You are the organization/group terminating a reassignment with an individual'.

Provide the middle initial of the delegated or authorized official. Fill only if 'Reason for submitting this application' is 'You are the organization/group terminating a reassignment with an individual'.

Provide the last name of the delegated or authorized official. Fill only if 'Reason for submitting this application' is 'You are the organization/group terminating a reassignment with an individual'.

Provide any applicable suffix or title for the delegated or authorized official, such as Jr., Sr., or M.D. Fill only if 'Reason for submitting this application' is 'You are the organization/group terminating a reassignment with an individual'.

Provide the effective date for your Medicare enrollment or benefits reassignment. Fill only if 'Enrolling/Enrolled in Medicare and Reassigning Benefits' is 'Yes'.

Please enter the first name of the individual practitioner.

Please enter the middle initial of the individual practitioner.

Please enter the last name of the individual practitioner.

Please enter any applicable suffix for the individual practitioner, such as Jr., Sr., or professional designations like M.D.

Please enter the Social Security Number (SSN) of the individual practitioner.

Please enter the Medicare Identification Number (PTAN) for the individual practitioner, if issued.

Please enter the National Provider Identifier (NPI) for the individual practitioner.

Enter the first name of the individual practitioner. Fill only if 'You are an individual practitioner terminating a reassignment with an organization/group' is 'Yes'.

Enter the middle initial of the individual practitioner. Fill only if 'You are an individual practitioner terminating a reassignment with an organization/group' is 'Yes'.

Enter the last name of the individual practitioner. Fill only if 'You are an individual practitioner terminating a reassignment with an organization/group' is 'Yes'.

Enter any suffixes or professional designations for the individual practitioner, such as Jr., Sr., or M.D. Fill only if 'You are an individual practitioner terminating a reassignment with an organization/group' is 'Yes'.

Provide the effective date for the organization or group terminating a reassignment with an individual. Fill only if 'Organization/Group Terminating Reassignment with Individual' is 'Yes'.

Provide the legal business name of the organization or group as it is reported to the Internal Revenue Service.

Enter the Tax Identification Number (TIN) for the organization or group.

Enter the Medicare Identification Number (PTAN) for the organization or group, if one has been issued.

Enter the National Provider Identifier (NPI) for the organization or group.

Enter the required text for Field 2 on Page 1.

Enter the required text for Field 3 on Page 1.

Enter the required text for Field 4 on Page 1.

Enter the effective date when the individual practitioner terminates reassignment with an organization or group. Fill only if 'Individual Practitioner Terminating Reassignment with Organization/Group' is 'Yes'.

Please enter the legal or 'Doing Business As' name for the primary practice location.

Please enter the street name and number for the primary practice location.

Please enter any additional address details such as suite, room, or apartment number for the primary practice location.

Please enter the city or town of the primary practice location.

Please enter the state of the primary practice location.

Please enter the 9-digit ZIP code for the primary practice location.

Please enter the PTAN (Medicare Identification Number) for this primary practice location, if it differs from the one reported in Section 2. Fill only if 'Medicare Identification Number (PTAN)' is different than PTAN reported in Section 2.

Please enter the NPI (National Provider Identifier) for this primary practice location, if it differs from the one reported in Section 2. Fill only if 'National Provider Identifier (NPI)' is different than NPI reported in Section 2.

Check this box if you are enrolling or are currently enrolled in Medicare and will be reassigning your benefits.

Check this box if you are an individual practitioner terminating a reassignment with an organization or group.

Check this box if you are the organization or group terminating a reassignment with an individual.

Provide the relationship or affiliation of the contact person to the individual or organization/group, such as Spouse, Secretary, Attorney, or Billing Agent.