Medicare Enrollment Application

Forms and Documents

Document Name	Status
Form CMS-855A Medicare Enrollment Application Form and Instruction	Modified
CMS-855 FORM COMMENTS OMB REPLY AUGUST 2007.DOC Supplementary Document	2007-11-05
CMS-855.Supporting Statement.doc Supporting Statement A	2007-11-05

IC Document Collections

IC ID	Document Title	Status
8284	Medicare Enrollment Application Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0685	ICR Reference No: 200711-0938-002
Status: Historical Active	Previous ICR Reference No: 200602-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/22/2008
	Date Received in OIRA: 11/15/2007
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2011	36 Months From Approved	04/30/2009
Responses	400,000	0	400,000
Time Burden (Hours)	1,001,503	0	1,000,000
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare enrollment application is used to gather information from providers and suppliers to participate in the Medicare program and to furnish services to Medicare beneficiaries. The information submitted is used uniquely to identify the providers and suppliers for the prupose of enumeration and payment.

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Authorizing Statute(s): US Code: 42 USC 1395f Name of Law: Conditions of and Limitations on Payment for Services
   US Code: 42 USC 1395g Name of Law: Payment to Providers of Services
   PL: Pub.L. 105 - 33 4313 Name of Law: Provision of certain identification numbers
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 1395u Name of Law: Provisions related to the Administration of Part B
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 26819	05/11/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 58096	10/12/2007
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Medicare Enrollment Application	CMS-855A, CMS-855B, CMS-855I, CMS-855R, CMS-855S	CMS-855A ,   CMS-855B ,   CMS-855I ,   CMS-855R ,   CMS-855S

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	400,000	400,000	0	0	0	0
Annual Time Burden (Hours)	1,001,503	1,000,000	0	1,503	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The burden increased slightly based on the revisions to the instruments CMS-855A and the CMS-855B.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 11/15/2007

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