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What is the 855B? ❖ The CMS form used for the enrollment of Clinic/Group practices and Certain Other Suppliers. This form is also used to submit changes to your enrollment data.
Starting November 1, 2023, you must use the revised form. Form updates: Combines the CMS-855I and CMS-855R paper applications and discontinues the CMS-855R.
All physicians, as well as all eligible professionals as defined in section 1848(k)(3)(B) of the Social Security Act must complete this application to enroll in the Medicare program and receive a Medicare billing number.
Complete and submit this application if you are an organization/group that plans to bill Medicare and you are: A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).
Send this completed application with original signatures and all required documentation to your designated MAC. The MAC that services your State is responsible for processing your enrollment application. To locate the mailing address for your designated MAC, go to CMS.gov/Medicare/Provider-Enrollment-and-Certification.

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CMS-855B: For group (all applicable sections). CMS-855I: For reassigning individuals who are new to the Medicare program, or not PECOS enrolled (sections 1, 2, 3, 4B, 13, and 15). CMS-855I: For employed physician assistants (sections 1, 2, 3, 13, and 15) CMS-855R: Individuals reassigning (entire application).
Form # CMS 855B. Form Title. Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers. Revision Date.
Change of Ownership (CHOW) is defined in 42 CFR 489.18 (a) and generally means, in the case of a partnership, the removal, addition, or substitution of a partner, unless the partners expressly agree otherwise, as permitted by applicable State law.

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