If the provider is a new enrollee, complete the entire application to add the reassignment.

To add, terminate, or change a reassignment, the individual or group would complete the following sections. Indicate on the CMS-855I a change of information, the reason of the submission, and follow the instructions.

Section 1A: REASON FOR SUBMITTING THIS APPLICATION
 

Section 1B: WHAT INFORMATION IS CHANGING?
 


 
Clarification for Section 15 (CERTIFICATION STATEMENT AND SIGNATURE)

If adding a reassignment both the individual provider(15B) and the authorized/delegated official of the group (15C) need to sign and date.

• If a Physician Assistant is adding an employment arrangement no 15C is needed.

If terminating/changing a reassignment either the individual provider(15B) OR the authorized/delegated official of the group (15C) need to sign and date.