Authorized Representative
As defined in the CMS 855A, an authorized representative is an appointed official to whom the provider has granted the legal authority to enroll it in the Medicare program, to make changes and/or updates to the provider's status in the Medicare program and to commit the provider to fully abide by the laws, regulations, and program instructions of Medicare. The authorized official must be the provider's general partner, chairman of the board, chief financial officer, chief executive officer, president, direct owner of 5% or more of the provider.
If an authorized representative leaves the company, the provider should update the CMS 855A as soon as possible. The application should include a cover letter explaining the change. A delegated official can not change the authorized representative, unless the delegated official has been appointed the authorized representative.
Type of Change
Adding an Authorized Representative
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6
Section 15
Type of Change
Deleting and Adding a new Authorized Representative
CMS 855A Sections Required
Section 1 (A.1,A.2,A.3)
Section 6 (Complete for new authorized representative)
Section 6 (Delete authorized representative that has left the company.)
Section 15
Please provide a cover letter explaining the change.
Actions Taken By Intermediary
Providers will receive a confirmation letter notifying them that the authorized representative has been changed.
Special Note - Please indicate at the bottom of the page if provider wants authorized representative to be primary contact.