Cms MedicareCMS-FormsDEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved OMB No 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your last name, first name, and middle initial. If necessary, attach a roster for additional names.
3. Fill in your license type if applicable, along with your primary and secondary specialties.
4. Provide your Federal TIN and Medicare number if you have one.
5. Complete the NPI sections: indicate whether you are an Individual (Type I) or Organization (Type II).
6. Update your old physical address and enter the new physical address along with practice name and DBA name.
7. Input your legal name, street address, city, state, ZIP code, and phone number for both old and new mailing addresses.
8. Include contact information such as email address and tax ID number. Remember to attach a completed W-9 form.
9. Specify the effective date of the changes and provide an authorized signature at the end of the form.

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