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Adding or Terminating a Reassignment to an Established Group

Table of Contents

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Adding Reassignment

Download CMS-855I

Complete sections 1A (Reporting a Change), 1B (Reassignment of Benefits), 2A, 4F, 12, 13 and 15B and C.

To add a new reassignment, both the individual practitioner and the group’s Authorized or Delegated Official currently on file must sign and date. Exception: Only need physician assistant signature and date.

Note: If an individual is newly enrolling to the state, or making other changes to individual enrollment information, complete and submit the CMS-855I version (5/23) , along with any required supporting documentation.

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Terminating Reassignment (By Individual)

Download CMS-855I

  • Complete sections 1A (Reporting a Change), 1B (Reassignment of Benefits), 2A, 4F, 12, 13 and 15B.

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Terminating Reassignment (By Organization)

Download CMS-855I

  • Complete sections 1A (Reporting a Change), 1B (Reassignment of Benefits), 2A, 4F, 12, 13 and 15C.

To terminate a reassignment, only one signature and date is required.

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Terminating Physician Assistant Employment Arrangement (by Organization)

Download CMS-855B

  • Complete sections 1, 2A1, 2F, 3 and 15.

Revised 7/29/2024

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J6 Mailing Address:

National Government Services, Inc.
P.O. Box 6475
Indianapolis, IN 46206-6475

Interactive Voice Response:

877-908-9499

Contact Enrollment:

877-908-8476

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. CT

Form(s) you'll need:

Enrollment Forms

Helpful Resources

Check Provider Enrollment Application Status
Log Into PECOS
Pay Application Fee

JK Mailing Address:

National Government Services, Inc.
P.O. Box 7149
Indianapolis, IN 46207-7149

Interactive Voice Response:

877-869-6504

Contact Enrollment:

888-379-3807

Hours Available:

Monday–Friday
8:00 a.m.–4:00 p.m. ET

Form(s) you'll need:

Enrollment Forms