Report a Change of Information

Report change of enrollment information timely. Changes can be either submitted electronically via PECOS or by mail with the paper CMS-855A and/or CMS-588 EFT agreement.

A change in the Tax ID with no ownership change will need to submit an initial enrollment for approval.

An ownership change (CHOW, merger/acquisition or consolidation) will need to submit an application for each entity involved, follow instructions on the CMS-855A for the situation.

A change in electronic funds transfer or bank information may be the only change required or it could be in addition to another change as indicated above, for assistance completing the CMS-588 EFT form, see Electronic Funds Transfer Form and Instructions.

PECOS Submission

Instructions for accessing and submitting existing enrollment information in PECOS:

Login to PECOS
Select My Associates
Scroll down under Existing Enrollment
Select “View Enrollment” for applicable enrollment
Select applicable enrollment record under Existing Enrollments
Select More Options
Select change of information and answer questionnaire(s)
Confirm reason for application
Select “Start Application”
Review and update appropriate “Topic View” section(s), which may include the following topics:
- Mailing Address
- Business/Physical Location and Special Payment Address
- Organizational or Individual Control
- Contact Person
- Electronic Funds Transfer
Upload supporting documents (if applicable)
Resolve all errors and verify warnings
Select “Begin Submission”
Proceed with the Electronic Signature or Upload Certification Process
Review and agree to Medicare regulations (Read and answer Attestation questions, if applicable)
Verify National Government Services as your contractor
Complete Submission button must be clicked to finish application
Print and/or save your submission confirmation and tracking number

Paper Submission

Download CMS-855A.

Complete the CMS-855A section 1A by selecting “You are changing your Medicare Information,” then in section 1B, check all that apply and complete the required sections as instructed.

When reporting ANY information, sections 1, 2B1, 3 and 15 MUST always be completed in addition to the information that is changing within the required section.

Note: Along with your application(s), submit the required supporting documentation to process the requested changes.

After the change has been submitted refer to the Provider Enrollment Application Process Timeline.

Report a Change of Information

PECOS Submission

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Paper Submission

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