Medicare and Other Federal Health Care Programs Provider/Supplier Enrollment Application -- 42 CFR 410.32, 410.71, 413.17, 424.57, 424.73, 424.80, and 484.12

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type

no available documents/forms check other ICs listed under this ICR

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Medicare and Other Federal Health Care Programs Provider/Supplier Enrollment Application -- 42 CFR 410.32, 410.71, 413.17, 424.57, 424.73, 424.80, and 484.12	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Migrated

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?
Form	HCFA-855S	No	No
Form	HCFA-855	No	No
Form	HCFA-855C	No	No
Form	HCFA-855R	No	No

Line of Business:

Subfunction:

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 225,000	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	225,000	202,500	22,500
Annual IC Time Burden (Hours)	435,000	0	435,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded

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