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Corporate

Sole Owner Changes

Sections of the 855I Application:

  1A 1B 2A 2B 2C 2D 2E 2F 2G 2H 3 4A(1) 4B 4C 6 8 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
ENTITY LEGAL BUSINESS NAME   X                 X X         X X
PRACTICE LOCATION   X                 X X X X     X X
SPECIAL PAYMENT ADDRESS   X                 X X   X     X X
INDIVIDUALS HAVING MANAGING CONTROL   X                 X X X   X   X X
BILLING AGENCY INFORMATION   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. Legal Business Name Change
    1. NPPESExternal website must be updated to reflect change of LBN.
    2. CP575 or other pre-printed IRSExternal website document must be included to show the name has been changed for the Tax Identification Number on file with them.
  3. 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.
  4. Changes to a Practice Location
    1. If there is a change in practice location, it must be reported to CMS within 30 days of the change occurring, or revocation of billing privileges may occur.

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