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Group Member Changes

Sections of the 855I Application:

data 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:

  1. Individual Name Change
    1. Provider's name must be updated with NPPESExternal website, state medical board, and SOCIAL SECURITY ADMINISTRATIONExternal website.
  2. Adverse Action
    1. All changes in adverse action must be accompanied by the proper legal Documentation that reflects the action & resolution that was taken in the matter.

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