This form is no longer available for Round 2 and the national mail-order competition.
Contract suppliers may request that locations be added to or removed from their contracts. Additions or removals may be requested at any time. All requests are subject to approval by the Centers for Medicare & Medicaid Services (CMS) and will be processed as quickly as possible.
Please complete and submit the form below if you wish to:
- Add a location(s) to your contract or
- Remove a location(s) from your contract.
Completed forms should be submitted to the 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 any requirement to add the location is not met, you will receive an e-mail that the request has been denied. You must submit a new form once the requirement(s) is met. The effective date will then be the receipt date of the form that confirms all requirements have been met.
You cannot furnish items under your contract using any new location until CMS has confirmed that it meets all applicable requirements and the necessary updates to the enrollment and claims processing systems have been completed. If you submit a claim using a new location's Provider Transaction Access Number (PTAN) before it has been approved, the claim will be denied.
If you have any questions about this form, 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.