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Last Modified: 6/6/2018 Location: FL, PR, USVI Business: Part B

Section 4 of the CMS-855R

Q: What information should be in Section 4 of the CMS-855R form?
A. The following information is required:

Initial Reassignment

Section 4A on page 6 is signed and dated by the person reassigning their benefits. Section 4B is signed and dated by the group’s authorized official or delegated official. If either signature is missing, First Coast Service Options Inc. (First Coast) will request this information as part of the development process.

Terminating Reassignments

If the individual terminates a reassignment, the individual signs and dates section 4A.
If the organization terminates a reassignment, the group’s authorized official or delegated official signs and dates Section 4B.
For terminations, both signatures are not required. However, if no signatures are present, First Coast will request this information as part of the development process.

Applicable to all CMS-855R applications

The authorized or delegated official who signs section 4B must be currently on file with First Coast. All signatures must be original, preferably in blue ink. Faxed, stamped, or photocopied signatures cannot be accepted.
If the application is not signed and dated appropriately, First Coast will send a development letter requesting this information. The corrected information will need to be returned within 30 days or the applications will be rejected.
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