Required sections on CMS applications
Dependent on your scenario, not all sections may be required when completing a CMS application. The chart below lists the required sections for initially enrolling providers / suppliers.
| Application Type / Scenario | Required Sections |
|---|---|
| CMS-855A | 1, 2, 3, 4, 6, 15 |
| CMS-855B | 1, 2, 3, 4, 6, 15 |
| CMS-855I - Individual Reassigning Benefits | 1, 2, 3, 4F, 15 |
| CMS-855I - Individual in Private Practice | 1, 2, 3, 4A, 4B, 4C, 4D, 15 |
| CMS-855I - Sole Proprietor/ Disregarded Entity | 1, 2, 3, 4A, 4B, 4C, 4D, 15 |
| CMS-855I - Sole Owner | 1, 2, 3, 4A, 4B, 4C, 4D, 4F, 15 |
| CMS-855O | 1, 2, 3, 4, 5, 8 |
| CMS-20134 | 1, 2, 3, 4, 6, 7, 15 |
Note: The required section lists all sections that are required for every specialty type. There are certain sections in each application that only apply to certain specialty types. If you find a section directed to your specialty type, fill out that section along with the sections referenced above.
Note: Section 13, Contact Person Section, of each application is not required. We do suggest completing this section if the individual who is filling out the application is not the provider, authorized, or delegated official. This also applies to Section 6 of the CMS-855O application for contact information.
Required sections - maintenance applications
The next chart below lists the required sections for our most common change of information applications- correspondence address change, contact person address change, authorized/delegated official change, practice location addition, and name change. If you are going through any of the changes below, follow the required sections to complete the appropriate application.
Note: Section 13, Contact Person Section, of each application is not required. We do suggest completing this section if the individual who is filling out the application is not the provider, authorized, or delegated official. This also applies to Section 6 of the CMS-855O application for contact information.
Correspondence address change
| Application type | Required sections for correspondence address change |
|---|---|
| CMS-855A | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 2C or 2D, 3, 15 |
| CMS-855B | 1A, 1B, 2A (Legal Business Name and Tax Identification Number), 2A3, 3, 15 |
| CMS-855I | 1A, 1B, 2A (First/Last Name, Date of Birth, and Social Security Number), 2D, 3, 15 |
| CMS-855O | 1A, 2A, 3, 5, 8 |
| CMS-20134 | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 2B3, 3, 15 (if authorized official) or 16 (if delegated official) |
Contact person address change
| Application type | Required sections for contact person address change |
|---|---|
| CMS-855A | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 13, 15 |
| CMS-855B | 1A, 1B, 2A (Legal Business Name and Tax Identification Number), 3, 13, 15 |
| CMS-855I | 1A, 1B, 2A (First/Last Name, Date of Birth, and Social Security Number), 3, 13, 15 |
| CMS-855O | 1A, 2A, 3, 6, 8 |
| CMS-20134 | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 13, 15 (if authorized signature) or 16 (if delegated official) |
Authorized / delegated official change
| Application type | Required sections for Authorized / Delegated Official change |
|---|---|
| CMS-855A | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 6, 15 |
| CMS-855B | 1A, 1B, 2A (Legal Business Name and Tax Identification Number), 3, 6, 15 |
| CMS-20134 | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 6, 15 (if authorized official) or 16 (if delegated official) |
Practice location addition
| Application type | Required sections for practice location addition |
|---|---|
| CMS-855A | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 4A, 15 |
| CMS-855B | 1A, 1B, 2A (Legal Business Name and Tax Identification Number), 3, 4A, 15 |
| CMS-855I | 1A, 1B, 2A (First/Last Name, Date of Birth, and Social Security Number), 3, 4B, 15 |
| CMS-20134 | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 4A, 15 (if authorized official) or 16 (if delegated official) |
Name change
| Application type | Required sections for name change |
|---|---|
| CMS-855A | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 15 |
| CMS-855B | 1A, 1B, 2A (Legal Business Name and Tax Identification Number), 3, 15 |
| CMS-855I | 1A, 1B, 2A (Legal Business Name, Date of Birth, and Social Security Number), 3, 15 |
| CMS-855O | 1A, 2A, 3, 8 |
| CMS-20134 | 1A, 1B, 2B (Legal Business Name and Tax Identification Number), 3, 15 (if authorized official) or 16 (if delegated official) |