Provider Information Change

The Centers for Medicare & Medicaid Services has established requirements and procedures for handling provider information change.

Does your organization need to file a request for one of the following?

  • Initial Medicare Enrollment
  • Change of Ownership, Acquisition/Merger, or Consolidation
  • Stock Transfer or Reorganization
  • Conversion to Critical Access Hospital
  • Additional Branch Location, including provider-based
  • Reactivation of a Previously Deactivation Medicare Provider Number
  • Change of Information for:
    • Legal Business or Doing Business As Name
    • Pay-to Address
    • Electronic Funds Transfer (EFT) Address
    • Correspondence/Practice Location Address
    • Managing/Directing Employee Change
    • Phone/Fax Number Change
    • Billing Agency

If so, a CMS-855A application is required. You’ll find more information in the Part A Enrollment Packet.

Where to Submit Correspondence

Completed applications or other correspondence related to Part A Medicare Enrollment may be mailed to the following address:

Cahaba Medicare Part A
Provider Enrollment
Post Office Box 6168
Indianapolis, IN  46206-6168

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