Change of practice address for Part A providers using the Medicare Enrollment Application - Institutional Providers (CMS-855A)

Section 1A: Reason for submitting this application

Select the reason for submitting the application:

• If you are performing a change of information, select 'You are changing your Medicare information

Section 1B: What information is changing?

Identify what information is changing:

• For changes to your practice location information, required sections are 1, 2B1, 3, 4A, 13 (optional), and 15B (authorized official signature) or 15C (delegated official signature)

For this guide, we are 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 2B1: Identification information

Provide the legal business name, tax identification number, national provider identifier, and Medicare identification number

• List the legal business name as it appears with the Internal Revenue Service (IRS)

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 4A: 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.

Hospital providers:

• Make sure to identify the type of practice location

If you are making multiple practice location changes:

• Print off additional pages for section 4A

Captures the person we will contact about the application.

Be sure to include all information, including the e-mail address.

• Authorized officials sign in section 15B
• Delegated officials sign in section 15D