Medicare Enrollment Application Reassignment Of Medicare Benefits {CMS-855R}

MEDICARE ENROLLMENT APPLICATION 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 American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-1179 Expires: 04/19 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). 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. 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. 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. 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 (04/16) American LegalNet, Inc. www.FormsWorkFlow.com 1 SECTION 1: BASIC INFORMATION REASON FOR SUBMITTING THIS APPLICATION You are enrolling or are currently enrolled in Medicare and will be reassigning your benefits You are an individual practitioner terminating a reassignment with an organization/group You are the organization/group terminating a reassignment with an individual Check the applicable box and complete the required sections. Effective Date (mm/dd/yyyy): Complete all sections Complete sections 1, 2, 3, 5, and 6A Complete sections 1, 2, 3, 5, and 6B Effective Date (mm/dd/yyyy): Effective Date (mm/dd/yyyy): SECTION 2: ORGANIZATION/GROUP RECEIVING THE REASSIGNED BENEFITS 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) 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 reassignme