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OMB Approval No. 0938-0685

MEDICARE AND OTHER FEDERAL

HEALTH CARE PROGRAMS

PROVIDER/SUPPLIER FORM

CHANGE OF INFORMATION

INSTRUCTIONS

Change of Information Form-HCFA 855C

Upon completion, return this form and all necessary documentation to:

MEDICARE REGISTRATION

P O BOX 44021

JACKSONVILLE, FLORIDA 32231-4021

General

This form is for reporting changes in provider/supplier information for Medicare or any other federal health care programs. All changes must be requested in writing and have an original signature. Faxed or photocopied signatures will not be accepted. Changes on this form are those made most frequently and may also be reported using HCFA Form 855, 855R, or 855S, as appropriate. All changes not on this form must be reported using HCFA Forms 855, 855R, or 855S.

This form is not to be used to report a change of ownership (CHOW) as defined in 42 CFR § 489.18. A change of ownership requires the new owner to submit a completed HCFA Form 855 (General Enrollment Application). However, the current owner should complete the Potential Termination of Current Ownership section of this form to report that a potential change of ownership may occur.

Check Type of Change Being Reported

Check all changes that apply.

1. Provider/Supplier Identification

Complete provider/supplier’s full name, social security number and employer identification number as it is currently on file at the Medicare or other federal health care contractor. The current Medicare or other federal health care program identification number must be provided (e.g. UPIN, NSC, OSCAR, PIN, NPI).

For legal business name, supply the name that the individual or entity uses in reporting to the Internal Revenue Service (IRS), as well as the individual’s or entity’s employer identification number (EIN) as it is currently on file at the Medicare or other federal health care contractor. If the EIN has changed, a new enrollment application (HCFA Form 855 or 855S) must be completed.

2. Name Change Information

If the provider/supplier is reporting a name change, complete applicable changes to the individual, organization or group name, and/or the “doing business as” name in the appropriate section. If an organization or group is requesting a name If the provider/supplier wishes to deactivate his/her Medicare or other federal health care program billing number, identify the type of Medicare or other federal health care program billing

change, an IRS Form CP 575 or other official IRS correspondence must be submitted showing the new name and the tax identification number related to the new name.

3. Address/Telephone Number Change Information

Complete provider/supplier’s new mailing address. This is where the provider/supplier receives notices from the Health Care Financing Administration or other federal health care programs.

Complete the “Pay To” address section if provider/supplier would like payments to go to an To” address currently on file. This address may be a Post Office box.

If the provider/supplier is reporting a billing agency or management service organization address change, complete identifying information for the current agency or organization and furnish the new address. If the provider/supplier is reporting a NEW billing agency or management service organization, do not use this form. Provider/supplier must complete the Provider/Supplier Identification and Billing Agency/Management Service Organization Address sections in the HCFA Form 855 (General Enrollment Application) and submit a copy of the new billing agreement or contract.

If provider/supplier is changing the location of the current practice, complete all information requested for the new location where provider/supplier will render services to Medicare or other federal health care program beneficiaries. If establishing a concurrent location (in addition to the current location), a new HCFA Form 855 (General Enrollment Application) must be completed for the new location. If deleting a current practice location, check the appropriate box.

A Post Office box or drop box is not acceptable as a practice location address. The phone number must be a number where patients and/or customers can reach the provider/supplier to ask questions or register complaints.

Indicate whether patient records are kept at the new practice location. If records are not kept at the new practice location, supply the physical address where the records are maintained. A Post Office or drop box address is notacceptable for records storage.

4. Provider/Supplier Specialty

Complete this section if provider/supplier’s primary and/or secondary specialty is changing.

5.Medicare or Other Federal Health Care Program Billing Number Deactivation Information

number (e.g. UPIN, NSC, OSCAR, CHAMPUS) and provide the billing number, the effective date of deactivation for that billing number, and the reason for deactivation. Provider/suppliers

HCFA 855C (1/98)

OMB Approval No. 0938-0685

may deactivate any and all Medicare or other federal health care program billing numbers as necessary by listing all applicable numbers, their types, and effective dates of deactivation as outlined above. However, applicant must notify each individual

federal agency regarding the deactivation of the number(s) 8. Potential Termination of Current Ownership under that agency’s control.

	When a business or organization is planning a change of
6. Addition/Deletion of Authorized Representative	ownership which is in accordance with the provisions for
	Change of Ownership (CHOW) as defined in 42 CFR § 489.18,
Complete this section if provider/supplier wishes to delete a	the current owner must furnish the name of				the potential new
currently listed authorized representative, or the	owner and the projected effective date of the potential change of
provider/supplier would like to report a new authorized	ownership as soon as the possibility of such an action is known
representative.	to the current owner.
An Authorized Representative is the appointed official (e.g.,	Note: This section is not to be completed when the
officer, chief executive officer, general partner, etc.) who has the	existing business/organization is adding or deleting a
authority to enroll the entity in Medicare or other federal health	new owner. Changes of individual owners should be
care programs as well as to make changes and/or updates to	reported using the appropriate sections of HCFA Form
the applicant’s status, and to commit the corporation to	855 (General Enrollment Application).
Medicare or other federal health care program laws and
regulations.	9. Effective Date of Change(s)
The original signature of the new authorized representative	Report the date all listed changes are effective.
is required to add a new authorized representative.
	10. Attestation Statement
7. Surety Bond Information
	Sign and date this form attesting to the accuracy of the
This section to be completed by all providers/suppliers for	requested changes.		If changes are being reported on an
which a surety bond is required.	individual	provider/supplier,		then	that	individual
	provider/supplier must sign this form. If the changes are being
Annual renewals must be reported to the Medicare or other	reported for an organization or group practice, an authorized
federal health care program contractor using this Change of	representative of the organization or group practice must sign
Information form - HCFA Form 855C.	this form to confirm the requested change(s).
An original copy of the surety bond must be submitted with
this form. Failure to submit an original copy of the surety
bond will prevent the processing of this form. In addition, the	THIS FORM SHOULD BE RETURNED TO YOUR
surety bond company must submit a certified copy of the	LOCAL MEDICARE OR OTHER FEDERAL HEALTH
agent’s Power of Attorney with this form, if the bond is issued	CARE PROGRAM CONTRACTOR. SEE THE RETURN
by an agent.	ADDRESS	AT	THE BEGINNING		OF	THESE

INSTRUCTIONS.

Note: It is the responsibility of the provider/supplier to obtain and submit with this form a certified copy of the surety bond agent’s Power of Attorney from the surety bond company, if the bond is issued by an agent.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938- 0685. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the

HCFA 855C (1/98)

OMB Approval No. 0938-0685

information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, P.O. Box 26684, Baltimore, Maryland 21207 and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.

III

HCFA 855C (1/98)

OMB Approval No. 0938-0685 066B

MEDICARE/FEDERAL HEALTH CARE PROVIDER/SUPPLIER FORM

Change of Information Form

Type of Change

(Check all that apply.)

Name	Practice Location Address
"Pay To" Address	Billing Agency Address
E-Mail Address	Authorized Representative

Potential Termination of Current Ownership

Mailing Address	Telephone Number(s)
Specialty	Fax Number(s)

Deactivation of Medicare Billing Number(s) Surety Bond Change or Renewal Information

1. Provider/Supplier Identification			(Required)
Individual Name:	First		Middle	Last			Jr., Sr., etc.	M.D., D.O., etc.

Other Name:	First		Middle	Last			Jr., Sr., etc.	M.D., D.O., etc.
OR
Business Name:

Social Security Number (if applicable)		Employer Identification Number (if applicable)			Medicare Identification Number(s) (if applicable)


2. Name Change Information
A. Individuals ONLY
Prior Name:	First		Middle	Last			Jr., Sr., etc.	M.D., D.O., etc.

New Name: First			Middle	Last			Jr., Sr., etc.	M.D., D.O., etc.

Social Security Number (if applicable)		Employer Identification Number (if applicable)			Medicare Identification Number(s) (if applicable)

B. Organizations or Groups ONLY
New Legal Business Name						Employer Identification Number

C. "Doing Business As" Name

Under what new name do you conduct business?

3.Address/Telephone Number Change Information

A.Mailing Address

New Mailing Address Line 1

New Mailing Address Line 2

New City		New State		New ZIP Code + 4

New Telephone Number		New Fax Number		New E-mail Address
(	)	(	)

B. "Pay To" Address

New Mailing Address Line 1

New Mailing Address Line 2

New City

New State

New ZIP Code + 4

New Telephone Number

()

HCFA 855C (1/98)

OMB Approval No. 0938-0685 066B

3.Address/Telephone Number Change Information (continued)

C.Billing Agency/Management Service Organization Address

Attach a copy of the most current signed contract with provider/supplier's billing agency or management service organization.

Name of Billing Agency/Management Service Organization						Employer Identification Number

Agency/Organization		First	Middle		Last	Jr., Sr., etc.	Title
Contact Person Name:

New Telephone Number			New Fax Number			New E-mail Address
(	)		(	)

New Business Street Address Line 1

New Business Street Address Line 2

New City

New State

New ZIP Code + 4

D. Practice Location(s)

(For each additional location, copy and complete this section.)

Check whether adding or deleting the practice location identified below.

Adding

Deleting

New Street Address Line 1

New Street Address Line 2

New City		New County		New State	New ZIP Code + 4

New Telephone Number		New Fax Number		New E-mail Address
(	)	(	)

Are all patient records stored at this new practice location?

Yes

No	IF NO, supply storage location below.

Name of New Storage Facility/Location

New Street Address Line 1

New Street Address Line 2

New City		New County		New State	New ZIP Code + 4

New Telephone Number		New Fax Number		New E-mail Address
(	)	(	)

4. Provider/Supplier Specialty Change Information

New Primary Specialty

New Secondary Specialty

5. Medicare or Other Federal Health Care Program Billing Number Deactivation Information

Type (OSCAR, UPIN, PIN, etc.)

Medicare/Other Federal Health Care Program Number Effective Date of Deactivation

(MM/DD/YYYY)

Reason for deactivation request?

6. Addition/Deletion of Authorized Representative

For each additional authorized representative, copy and complete this section.

Addition of Authorized Representative				Deletion of Authorized Representative
Effective date				Effective date
(MM/DD/YYYY)				(MM/DD/YYYY)
(MM/DD/YYYY)				(MM/DD/YYYY)
Authorized Representative Name:		First	Middle		Last	Jr., Sr., etc.	M.D., D.O., etc.
(printed)
Title/Position		Social Security Number			Medicare Identification Number(s)
					(if applicable)
Authorized Representative	(First, Middle, Last, Jr., Sr., M.D., D.O., etc.)					Date
Signature						(MM/DD/YYYY)

HCFA 855C (1/98)

OMB Approval No. 0938-0685 066B

7. Surety Bond Change or Renewal Information

An original copy of the current surety bond must be submitted with this section.

A certified copy of the surety bond agent's Power of Attorney must be submitted with this section.

Name of Surety Bond Company

Telephone Number

()

Fax Number

()

Agent's Name:	First	Middle	Last
Amount of Surety Bond		Effective Date
Amount of Surety Bond		Effective Date
$		(MM/DD/YYYY)
Bond for Tax Year:		Annual Renewal Date
		(MM/DD/YYYY)

Jr., Sr., etc.

8. Potential Termination of Current Ownership

Furnish name of potential new owner and projected effective date of change of ownership.

Individual Name of Potential New Owner: First	Middle	Last	Jr., Sr., etc.	M.D., D.O., etc.
OR
Legal Business Name of Potential New Owner:

Projected Effective Date of Change of Ownership (MM/DD/YYYY)

Medicare Identification Number of Potential New Owner (if applicable)

9. Effective Date of Change(s)

This change/these changes are effective as of

(MM/DD/YYYY)

10. Attestation Statement

I certify that I have examined the above information and that it is true, accurate and complete. I understand that any misrepresentation or concealment of material information may subject me to liability under civil and criminal laws.

Provider/Supplier Name:	First		Middle	Last		Jr., Sr., etc.	M.D., D.O., etc.
(printed)
Provider/Supplier Signature		(First, Middle, Last, Jr., Sr., M.D., D.O., etc.)			Date
					(MM/DD/YYYY)

or for groups and organizations:

Authorized Representative Name:		First		Middle	Last		Jr., Sr., etc.	M.D., D.O., etc.
(printed)
Title/Position			Social Security Number			Medicare Identification Number (if applicable)

Authorized Representative	(First, Middle, Last, Jr., Sr., M.D., D.O., etc.)					Date
Signature						(MM/DD/YYYY)

HCFA 855C (1/98)

Question	Answer
Form Name	855C Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	hcfa, YYYY, 855 c, 066B

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