Information Collection

Medicare Health Care Provider Enrollment Application and Supporting Regulations -- 42 CFR 405.2401; 410.40, .69; 491.2; 414.451, .52, .56, .60; 424.57, .73; 440.30

IC 8277 under ICR 199703-0938-001 · OMB 0938-0685.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0685 can be found here:

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Information Collection (IC) Details

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IC Title:	Medicare Health Care Provider Enrollment Application and Supporting Regulations -- 42 CFR 405.2401; 410.40, .69; 491.2; 414.451, .52, .56, .60; 424.57, .73; 440.30	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	855G	No	No
Form	855C	No	No
Form	855	No	No
Form	855S	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 165,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	165,000	5,000	160,000
Annual IC Time Burden (Hours)	370,000	130,000	240,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.