Voluntary Termination
CMS 855A Sections Required
Section 1.A.1. - Check Voluntary Termination of Billing Number
Include the effective date.
Section 6 (if provider does not have a CMS 855A on file)
Section 15 must be signed.
Please note that the intermediary will notify the state agency of the termination notice. The state agency will notify CMS. The provider number will not be terminated in Palmetto GBA systems until CMS notification of termination has been received. Therefore, it is possible that the provider may continue to receive correspondence from Palmetto GBA until the CMS notice is received and processed.