(Basic Information) – Form CMS-855I

10.3.1.3.1 - Section 1 (Basic Information) – Form CMS-855I (Rev. 13355; Issued: 08-13-25; Effective: 05-05-25; Implementation: 05-05-25) A. Purpose and Verification In this section, the supplier indicates the reason for submittal of the application. (This includes establishing, terminating, or changing reassignments.) 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 voluntarily terminating an enrollment as one supplier type and enrolling as a different supplier type; both transactions cannot be reported on the same application. Excluding (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., the PCV, e-mail, telephone, fax). B. Voluntary Termination Reminder When a practitioner submits a Form CMS-855I application to either (1) add a practice location in a new state or (2) relocate to a new state entirely, the contractor that received the application shall determine whether the practitioner still has an active PECOS enrollment record in the “other” state(s). If PECOS indeed indicates that the individual has an active practice location in the other state(s), the contractor should remind the practitioner that if the latter no longer intends to practice in that state, the individual must submit a Form CMS-855I voluntary termination application to the contractor for that jurisdiction. The reminder should be furnished in the approval letter that the receiving contractor sends to the practitioner or, if more appropriate, via the PCV, e-mail, or other form of written correspondence. C. Break in Medical Practice If the contractor receives a Form CMS-855I from a practitioner who was once enrolled in Medicare but has not been enrolled with any Medicare contractor for the previous 2 years, the contractor shall verify with the state (a) where the practitioner last worked and (b) whether the practitioner was convicted of a felony or had licensure suspended or revoked. If such an adverse action was imposed, the contractor shall take action consistent with the instructions in this chapter.