Sole Proprietor Changes
Sections of the 855I Application:
1A | 1B | 2A | 2B | 2C | 2D | 2E | 2G | 2H | 3 | 4A(1) | 4B | 4C | 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 | ||||||||
PRACTICE LOCATION | X | X | X | X | X | X | X | |||||||||
SPECIAL PAYMENT ADDRESS | 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:
- Individual Name Change
- Provider's name must be updated with NPPES, state medical board, and SOCIAL SECURITY ADMINISTRATION.
- Legal Business Name Change
- 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.
- Changes to a Practice Location
- 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.