Information Collection

Medicare Enrollment Application

IC 8284 under ICR 200711-0938-002 · OMB 0938-0685.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855A Medicare Enrollment Application	Form and Instruction
CMS-855A CMS-855A CMS-855A.pdf	Form and Instruction
CMS-855B CMS-855B CMS-855B.pdf	Form and Instruction
CMS-855I CMS-855I CMS-855I.pdf	Form and Instruction
CMS-855R CMS-855R CMS-855R.pdf	Form and Instruction
CMS-855S CMS-855S CMS-855S.pdf	Form and Instruction

IC Title:

Medicare Enrollment Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855A	CMS-855A	CMS-855A.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-855B	CMS-855B	CMS-855B.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-855I	CMS-855I	CMS-855I.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-855R	CMS-855R	CMS-855R.pdf	Yes	No	Fillable Printable
Form and Instruction	CMS-855S	CMS-855S	CMS-855S.pdf	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400,000

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	400,000	0	400,000
Annual IC Time Burden (Hours)	1,001,503	1,503	1,000,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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