Medicare Enrollment Application

⚠️ Notice: This information collection may be referencing outdated material.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
Form CMS-855I Medicare Enrollment Application Form and Instruction
CMS-855I CMS-855I CMS_855I_CHECK_DONE_FINAL.pdf Form and Instruction
CMS-855A CMS-855A CMS_855A_CHECK.pdf Form and Instruction
CMS-855B CMS-855B CMS_855B_CHECK_DONE_FINAL.PDF Form and Instruction
CMS-855R CMS-855R CMS_855R_CHECK_DONE_FINAL.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855I	CMS-855I	CMS_855I_CHECK_DONE_FINAL.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-855A	CMS-855A	CMS_855A_CHECK.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-855B	CMS-855B	CMS_855B_CHECK_DONE_FINAL.PDF	Yes	Yes	Fillable Fileable
Form and Instruction	CMS-855R	CMS-855R	CMS_855R_CHECK_DONE_FINAL.pdf	Yes	Yes	Fillable Fileable

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 %

	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)	785,702	-215,801	1,001,503
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.