Tutorial: Change of Practice Address for Part A Providers (Using CMS-855A)

Changing a Practice Address on the CMS-855A Form

Step 1

Select “You are changing your Medicare information” in Section 1:  Basic Information.

Enter your Medicare Identification Number (CCN) and NPI in the spaces provided.

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

Step 2

Select “Practice Location Information, Payment Address and Medical Storage Information” in Section 1B. 

The column title “Required Sections” lists the sections to complete for the change as 1, 2B1, 3, 4 (complete only those sections that are changing), 13 and either 15 (if you are an authorized official) or 16 (if you are a delegated official) and 6 for the signer if that authorized or delegated official has not been established for this provider. 

Proceed to Section 2B1.

Step 3

Section 2B1: Identifying Information. 

Section 2 is divided into Parts A through H.  Complete ONLY the Business Information in Section 2B1. 

Proceed to Section 3.

Step 4

Complete Section 3: Final Adverse Actions/Convictions.

Proceed to Section 4.

Step 5

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

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 and proceed to Section 13.

Step 6

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 15.

Step 7

Section 15: 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 16A.

Step 8

Section 16:  Part A in Section 16 is provided for the Delegated Official’s Signature. 

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

Step 9

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 (JH) (JL) 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 Novitas Solutions. Mailing addresses can be found below:

Jurisdiction L (JL): Delaware, Maryland, New Jersey, Pennsylvania, Washington, D.C.

Novitas Solutions
Provider Enrollment Services
P.O. Box 3157
Mechanicsburg, PA 17055-1836

Jurisdiction H (JH): Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas

Novitas Solutions
Provider Enrollment Services
P.O. Box 3095
Mechanicsburg, PA 17055-1813

Jurisdiction H (JH): Indian Health Service/Tribal Providers

Novitas Solutions
Provider Enrollment Services
P.O. Box 3115
Mechanicsburg, PA 17055-1858