How do I voluntarily terminate or deactivate my Medicare enrollment?

Submit the applicable CMS-855 application to voluntarily terminate your Medicare enrollment or to deactivate your reassignment. Complete the appropriate paper application sections listed below or go to PECOS to submit the electronic application.

• Medicare Enrollment Application - Physicians and Non-Physician Practitioners (CMS-855I)
  • Individuals must complete sections 1A, 2A, 13 (optional) and 15
  • For reassignment terminations (including physician assistants):
  • Complete sections 1A, 2A, 4F, 13 (optional), and either 15B (individual signature) or 15C (authorized or delegated signature)
• Medicare Enrollment Application – Clinics / Group Practices and Other Suppliers (CMS-855B)
  • Complete sections 1, 2A1, 13 (optional) and 15
  • Terminating an employment arrangement with a physician assistant must complete sections 1, 2A1, 2F, 13 (optional) and 15
• Medicare Enrollment Applications - Institutional Providers (CMS-855A)
  • Complete sections 1, 2B1, 13 and either 15 or 16
• Medicare Enrollment Application - Medicare Diabetes Prevention Program (MDPP) Suppliers (CMS-20134)
  • Complete sections 1, 2B1, 13 (optional) and either 15 or 16
• Medicare Enrollment Application - Ordering and Referring Physicians and Non-Physician Practitioners (CMS-855O)
  • Complete sections 2A (name, SSN, and NPI) and 8

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