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Last Modified: 4/27/2020 Location: FL, PR, USVI Business: Part A, Part B

Voluntary termination

Q: What should be done when leaving an office, closing a private practice, or retiring?
A: You must notify Medicare when voluntarily terminating an enrollment. Voluntary terminations may include:
Leaving a practice or organization (terminating a reassignment)
Closing a private practice
Retiring
Moving to another state to render services
Any situation where you will no longer render and bill services for a practice or organization
This notification must take place using internet-based Provider Enrollment, Chain and Ownership System (PECOS) or by completing the appropriate CMS-855 application.
The direct link for each Medicare provider/supplier enrollment application is shown below:
CMS 855B for Clinics/Group practices and Certain Other Suppliers: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855b.pdf external pdf file
CMS 855I for Physicians and Non-Physician Practitioners: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf external pdf file
CMS 855R for Reassignment of Medicare Benefits: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855r.pdf external pdf file
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First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.