Change of Tax ID Instructions and Forms

Table of Contents

• Certified Providers and Certain Other Suppliers
• Clinics/Group Practices
• Sole Owner/Sole Proprietor
• Effective Dates When Changing a Tax ID For Clinics/Group Practices

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Certified Providers and Certain Other Suppliers

• Complete the CMS-855B Medicare Enrollment Application form for Clinics/Group Practices and Certain Other Suppliers.

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Clinics/Group Practices

• Complete the CMS-855B Medicare Enrollment Application form for Clinics/Group Practices and Certain Other Suppliers; and
• Complete the CMS-855I Medicare Enrollment Application form for Physicians and Non-Physician Practitioners for each physician or nonphysician practitioner reassigning benefits to the new tax ID.

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Sole Owner/Sole Proprietor

• Complete the CMS-855I Medicare Enrollment Application form for Physicians and Non-Physician Practitioners for individual in private practice either as an incorporated sole owner or sole proprietor using an employer ID number.

This can be completed using the paper form or online using the Internet-based PECOS.

Forward your completed forms to the appropriate National Government Services office.

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Effective Dates When Changing a Tax ID For Clinics/Group Practices

If both the application for the clinic/group practice and the reassignment of benefits applications are submitted together and all enrollment requirements are met, all will have the same effective date.

Any reassignment of benefits application submitted after the clinic/group practice application, the individual provider’s effective date will be based on the date the approved reassignment of benefits application is received per CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 10, Section 10.6.2.

Revised 7/29/2024