This form is no longer available for Round 2 and the national mail-order competition.
Please complete and submit the form below if you wish to:
- Change an authorized official to another authorized official on your enrollment file in the Provider Enrollment, Chain, and Ownership System (PECOS) and with the National Supplier Clearinghouse (NSC), or
- Add or remove a backup authorized official who is an authorized official on file with the NSC, or
- Change an e-mail or phone number for the authorized official or backup authorized official, or
- Add/update a toll-free number for the Supplier Directory on the Medicare website, or
- Update a contract correspondence mailing address
Completed forms should be submitted to the Competitive Bidding Implementation Contractor (CBIC) by one of two methods:
Fax (recommended): 803-264-6228
Mail: CBIC, 2743 Perimeter Pkwy Ste 200-400, Augusta, GA 30909-6499
Forms are processed within CMS' guidelines and may take up to 30 days to complete. If the CBIC requires additional information, the process may exceed 30 days. You will be notified via e-mail once your request is complete. The effective date of the approved request to add a location will be the date the form was received by the CBIC.
If you have any questions, please contact the CBIC customer service center at 877-577-5331 between 9 a.m. and 5:30 p.m. prevailing Eastern Time, Monday through Friday. Changes to your enrollment record must also be made in PECOS and with the NSC before they can be accepted by the CBIC. It is not necessary to notify the CBIC of a change of address. This information must be updated in PECOS and with the NSC within 30 days of the change in accordance with Supplier Standard #2.