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Corporate

Group Member Changes

Sections of the 855I Application:

  1A 1B 2A 2B 2C 2D 2E 2G 2H 3 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
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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