Complete the identified section of the CMS 855B application if you are changing any of the following information for a Group or Organization.
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|
Section |
Attachment |
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1 |
2* |
2B1 |
3 |
4* |
5 |
6** |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15*** |
16**** |
1* |
2* |
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Identifying Information |
X |
X |
|
X |
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|
X |
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|
X |
|
X |
X |
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Adverse Legal Actions/Convictions |
X |
|
X |
X |
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|
X |
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X |
X |
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Practice Location Information, Payment Address & Medical Record Storage Information |
X |
|
X |
X |
X |
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X |
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X |
|
X |
X |
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Change of Ownership
(Hospital, Portable X-Ray Suppliers & Ambulatory Surgical Centers Only) |
Complete all sections and provide a copy of the sales agreement. |
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Ownership Interest and/or Managing Control Information (Group/Organization) |
X |
|
X |
X |
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X |
X |
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X |
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X |
X |
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Billing Agency Information |
X |
|
X |
X |
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|
X |
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|
X |
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X |
X |
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Authorized/Delegated Official |
X |
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X |
X |
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|
X |
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X |
X |
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Ambulance Service Suppliers Only |
X |
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X |
X |
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|
X |
|
X |
X |
X |
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Independent Diagnostic Testing Facilities (IDTF) Only |
X |
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X |
X |
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|
X |
|
X |
X |
|
X |
* Complete only those sections that are changing.
** If authorized and/or delegated official is not established with the supplier
*** If authorized official is the signee
**** If delegated official is the signee