Do I need to complete a new provider enrollment form if I am making a change to my credentialing information?

Answer: If you need to make a change to an existing Medicare record, you must use one of the forms listed below. Letters, faxes and postal change-of-address notifications are not acceptable. The specific form needed depends on your provider type:

  • CMS 855B: This application is used to enroll new health care organizations, such as group practices, or to make changes to an existing health care organization’s Medicare records
  • CMS 855I: This application is used to enroll new individual physicians or nonphysician practitioners, or to make changes to an existing individual physician or nonphysician practitioner’s Medicare records
  • CMS 855R: This application is used to reassign an individual physician’s or nonphysician practitioner’s Medicare benefits (reimbursement) to a group, or if the individual physician or nonphysician practitioner is making a change to an existing re-assignment agreement

Options

  • Download the appropriate CMS 855 form (JJ or JM) from the Enrollment Application Finder tool. Once downloaded, complete all appropriate fields, print, sign and mail the form to Palmetto GBA.
  • Complete and submit your application through PECOS website. Your application may be processed up to 50 percent faster than applications submitted on paper.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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