Subscribe to eNews Contact us

Tutorial: Change of practice address for Part B group / organization providers (Using CMS-855B)

Changing a practice address on the CMS-855B form

Step 1

Select you are reporting a change to your Medicare enrollment information

Select “You are reporting a change to your Medicare enrollment information” in Section 1: Basic Information.

Proceed to Section 1B as noted in the far-right column.

Step 2

Picture of part of the application. Select Private Practice Business Information.

Select “Private Practice Business Information” in Section 1B.

The column title “Required Sections” lists the sections to complete for the change as 1, 2A, 3, 4A, 12, 13 (optional) and 15 and 6 for the signer if that authorized or delegated official has not been established for this provider.

Proceed to Section 2A1.

Step 3

Picture of Section A of the application. You need to provide the supplier identification information in section 2A.

Section 2A1: Supplier Identification Information.

Section 2 is divided into Parts A through G. Complete ONLY the Business Information in Section 2A1.

Proceed to Section 3.

Step 4

Here is a screenshot of the final adverse legal action section.

Complete Section 3 – Final Adverse Actions / Convictions.

Proceed to Section 4.

Step 5

Here is a screenshot of the practice location information.

Section 4: Practice Location Information is divided into Parts A through G.

Complete ONLY THE PARTS WHICH HAVE CHANGES. For example, Section 4B pertains to Remittance Notices and Special Payments. If the information for Remittance Notices and Special Payments has not changed, the fields should remain blank. Complete the information which has changed.

Note: Prior to terminating a practice location, where the NPI linked to that location is not linked to any other practice location(s), please ensure all outstanding claims have been submitted and processed by Medicare.

Proceed to Section 13.

Step 6

Here is a screenshot of the contact person section.

Section 13: Contact Person.

Complete the Contact Person’s information. The person will be contacted regarding the application, but if a contact person is not listed, the provider will be directly contacted.

Proceed to Section 15B.

Step 7

Here is a screenshot of the authorized official signature page.

Section 15B. Certification Statement is the section in which a signature (preferably blue ink) certifies the submitted information.

The signature must be the Authorized Official’s signature.

If the Delegated Official is signing, proceed to Section 15D.

Step 8

Here is a screenshot of the delegated official signature page.

Section 15D: Section 15D is provided for the Delegated Official’s Signature.

If the Authorized Official or the Delegated Official has not been established for the provider, proceed to Section 6.

Step 9

Here is a screenshot of the individuals with ownership interest and/or managing control.

Section 6: Ownership Interest and/or Managing Control Information must be completed if the Authorized Official or the Delegated Official has not been established for the provider.

Step 10

Our Enrollment Gateway allows you the option to upload your paper enrollment application instead of mailing. For more information, please refer to our Enrollment Gateway User Guide.

If you decide to mail the application, you will need to mail the completed, signed form and all supporting documentation to First Coast. Mailing addresses can be found below:

Jurisdiction N (JN): Florida, Puerto Rico, U.S. Virgin Islands

First Coast Service Options
Provider Enrollment Services
P.O Box 3409
Mechanicsburg, PA 17055-1849