Providers may change their Legal Business Name or Doing Business as Name for various reasons. In order for Medicare to recognize the name change, please submit the CMS 855A with the sections listed below.
CMS 855A Sections Required
Section 1.A.1, 1.A.2, 1.A.3
Section 2.B.1, 2.B.2 (if applicable), check the Change Box and list the effective date.
Section 6 - Must be completed for authorized representative if no application is on file.
Section 15 - Must be signed by the authorized representative or delegated official.
Supporting Documentation Required
Legal document, such as CP 575, Secretary of State documents.
Actions Taken by Intermediary
A confirmation letter will be sent to the provider.
A copy of the confirmation letter will be forwarded to the appropriate state agency.