(Basic Information) - Form CMS-855B

10.3.1.2.1 – Section 1 (Basic Information) - Form CMS-855B (Rev. 11839; Issued: 02-09-23; Effective: 04-21-23; Implementation: 06-19-23) In this section, the supplier indicates the reason for submittal of the application. Unless otherwise stated in this chapter, in another CMS directive, or as permitted by PECOS, the supplier may only check one reason for submittal. For example, suppose a supplier is changing its tax identification number via the Form CMS-855B. The supplier must submit two applications: (1) an initial Form CMS-855B as a new supplier; and (2) a Form CMS-855B voluntary termination. Both transactions cannot be reported on the same application. With the exception of (1) the voluntary termination checkbox and (2) the effective date of termination data in the Basic Information section of the Form CMS-855B---and except as stated in section 10.6.1.3 of this chapter---any blank data/checkboxes in this section can be verified through any means chosen by the contractor (e.g., e-mail, the PCV, telephone, fax).