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Change of practice address for individual Part B providers using the Medicare Enrollment Application - Physicians and Non-Physician Practitioners (CMS-855I)

Individuals in private practice, sole proprietors, disregarded entities, and sole owners will complete the Physicians and Non-Physician Practitioners (CMS-855I) application for practice location changes. 

The chart below is designed to provide additional instructions on completing the enrollment application. Please make sure to follow the guidelines listed on the application.

Note: Once you complete the application, you can either upload the application on the Provider Enrollment Gateway or mail the application to us.

Section of form Helpful hints
Section 1: Basic information

Section 1A: Reason for submitting this application

Select the reason for submitting the application: 

  • If you’re performing a change of information, select “You are reporting a change to your Medicare enrollment information.” 

Section 1B: What information is changing?

Identify what information is changing:

  • For changes to your private practice business information, required sections are 1, 2A, 3, 4A, 12, 13 (optional), and 15

For this guide, we’re only changing the practice location information. If you have additional changes, make sure to refer to this section for the required sections to make the change.
Section 2: Personal identifying information

Section 2A: Individual information

Provide the practitioner’s name, social security number, date of birth, NPI, and Medicare identification number (PTAN).

List the practitioner’s name as it appears with the Social Security Administration (SSA): 

  • If you had a name change, your name must be updated with the SSA and National Plan and Provider Enumeration System (NPPES) before you can update your Medicare enrollment record. 
Section 3: Final adverse legal actions

Section 3C: Final adverse legal action history

Answer the final adverse legal action question:

  • Make sure to include a copy of all final adverse legal action documentation and resolution, if applicable. 
Section 4: Business information

Section 4B: Practice location information

Complete this section with the new practice information.

Check the change, add, or remove box, and provide the date of the practice location change. 

Be sure to include the date you saw your first Medicare patient at this location and type of practice location. 

If you are making multiple practice location changes: 

  • Print off additional pages for section 4B

Note: Your practice location must be the physical location where you render services to Medicare beneficiaries. Your practice location address cannot be a Post Office (P.O.) box, commercial mailbox, or a drop box.
Section 12: Supporting documentation information If you have any supporting documents, make sure to include the documents with your application submission. 
Section 13: Contact person information

Captures the person we will contact about the application.

Be sure to include all information, including the email address.
Section 15: Certification statement and signature

Section 15: Certification statement and signature

Signatures must be handwritten or an eligible digital signature.

Section 15B: Signature and date

Individual practitioner must sign this application:

  • Authority to sign on your behalf cannot be delegated