Do I need to complete a new provider enrollment form if I am making a change to my credentialing information?

Answer:
If you need to make a change to an existing Medicare record, you must use one of the forms listed below. Letters, faxes and postal change of address notifications are not acceptable. The specific form needed depends on your "provider type:"

  • CMS 855B: This application is used to enroll new health care organizations, such as group practices, or to make changes to an existing health care organization’s Medicare records
  • CMS 855I: This application is used to enroll new individual physicians or non-physician practitioners, or to make changes to an existing individual physician or non-physician practitioner’s Medicare records
  • CMS 855R: This application is used to re-assign an individual physician’s or non-physician practitioner’s Medicare benefits (reimbursement) to a group, or if the individual physician or non-physician practitioner is making a change to an existing re-assignment agreement

Options:

  • Download the appropriate CMS 855 form from the Enrollment Application Finder tool. Once downloaded, complete all appropriate fields, print, sign and mail the form to Palmetto GBA.
  • Complete and submit your application through PECOS website. Your application may be processed up to 50 percent faster than applications submitted on paper.

Contact Palmetto GBA JM Part B Medicare

Email Part B

Contact a specific JM Part B department

Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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