Group Member Changes
Sections of the 855I Application:
1A | 1B | 2A | 2B | 2C | 2D | 2E | 2G | 2H | 3 | 4F | 13 | 15 | |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
INDIVIDUAL PROVIDER NAME | X | X | X | X | X | X | X | X | |||||
CORRESPONDENCE ADDRESS | X | X | X | X | X | X | X | X | X | X | |||
INDIVIDUAL SPECIALTY | X | X | X | X | X | X or X | X | X | X | ||||
INDIVIDUAL/ORGANIZATION/GROUP RECEIVING REASSIGNED BENEFITS | X | X | X | X | X | X | |||||||
ADVERSE LEGAL ACTIONS/CONVICTIONS | X | X | X | X | X | X | X | X |
Additional Information/Documentation may be needed to process specific changes:
- Individual Name Change
- Provider's name must be updated with NPPES, state medical board, and SOCIAL SECURITY ADMINISTRATION.
- Adverse Action
- All changes in adverse action must be accompanied by the proper legal Documentation that reflects the action & resolution that was taken in the matter.