Change in Management Personnel & Board Members
Section 6
Type of Change
Management Personnel/Board Members
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 for new personnel. Personnel should also be deleted with an effective date provided on the CMS 855A.
Section 6 (for authorized representative, if no application is on file.)
Section 15
Special Note- Please indicate at the bottom of the page of the application if the person added should be a primary contact for the provider.
Actions Taken By Intermediary
Providers will receive a confirmation letter notifying them that the change has been recognized. State agencies will be notified by copy of this letter of medical staff changes, i.e., Administrator, Director of Nursing. All other management changes are not communicated to the state agency.