(Basic Information) - Form CMS-855A

10.3.1.1.1 – Section 1 (Basic Information) - Form CMS-855A (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) In Section 1, the provider indicates the reason for submittal of the application. Unless otherwise stated in this chapter or in another CMS directive, or as permitted by PECOS, the provider can only check one reason for submittal. With the exception of (1) the voluntary termination checkbox and (2) the effective date of termination---and except as stated in section 10.6.1.3 of this chapter---any blank data/checkboxes in the Basic Information section can be verified through any means (e.g., e-mail, the PCV, telephone, fax).