Voluntary termination

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Home ► FAQs ► Answers ► Voluntary termination

Last Modified: 2/10/2025 Location: FL, PR, USVI Business: Part A, Part B

Voluntary Terminations

A certified provider or supplier that wishes to terminate its agreement with Medicare must send a written notice of its intention to the CMS Survey & Operations Group (SOG) location, the state agency or the contractor within the timeframes addressed in § 489.52. Under CMS Publication (Pub.) 100-07, chapter 2, section 2005F, the notice is a letter on letterhead with an authorized signature.

Submission of a form CMS-855 voluntary termination application is not mandatory but is highly preferred. Providers and suppliers are encouraged to continue to submit this form.

If the provider or supplier's submission is missing either the effective date of termination or the reason for the termination, we will develop for the missing or unclear data. The provider or supplier must furnish the data via a written format.

If you chose to voluntarily terminate your enrollment via a written notice, the written notice must:

• Be on the provider or supplier's letterhead

• Contain the provider or supplier's legal business name, NPI, and CMS Certification Number (CCN)

• State with sufficient clarity that the provider or supplier wishes to terminate its Medicare provider or supplier agreement or enrollment

• Signed and dated by an authorized representative of the provider or supplier

• This person need not be on file as an authorized or delegated official of the provider or supplier.

If the written notice requirements are not met, we will develop for the information.

Please refer to CMS IOM Pub. 100-08 Program Integrity Manual, Chapter 12 external pdf file

for more information.

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