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Cms MedicareCMS-FormsDEPARTMENT OF HEALTH AND HUMAN SERVICES Form Approved OMB No 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your last name, first name, and middle initial. If necessary, attach a roster for additional names.
- Fill in your license type if applicable, along with your primary and secondary specialties.
- Provide your Federal TIN and Medicare number if you have one.
- Complete the NPI sections: indicate whether you are an Individual (Type I) or Organization (Type II).
- Update your old physical address and enter the new physical address along with practice name and DBA name.
- Input your legal name, street address, city, state, ZIP code, and phone number for both old and new mailing addresses.
- Include contact information such as email address and tax ID number. Remember to attach a completed W-9 form.
- Specify the effective date of the changes and provide an authorized signature at the end of the form.
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Related links
Form CMS-L564 (CMS-R-297) (0 9/1 6). 1. DEPARTMENT OF HEALTH AND HUMAN SERVICES. CENTERS FOR MEDICARE MEDICAID SERVICES. Form Approved. OMB No. 0938-0787.Read more
Aug 8, 2006 These requirements are not effective until they are approved by OMB. VI. Regulatory Impact Analysis. A. Overall Impact. We have examined theRead more