Complete the identified section of the CMS 855I application if you are changing any of the following information for an Individual, a Sole Proprietor or a Sole Owned Organization.
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Section |
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1 |
2* |
2A |
3 |
4* |
5 |
6 |
7 |
8* |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
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Identifying Information |
X |
X |
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X |
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X |
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X |
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Adverse Legal Actions/Convictions |
X |
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X |
X |
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X |
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X |
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Practice Location Information, Payment Address & Medical Record Storage Information |
X |
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X |
X |
X |
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X |
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X |
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Individuals having Managing Control |
X |
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X |
X |
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X |
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X |
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X |
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Billing Agency Information |
X |
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X |
X |
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X |
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X |
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X |
* Complete only those sections that are changing.