Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12)

Medicare Enrollment Application (Form 855S)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1056 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12) Form
CMS-855S CMS-855S CMS-855S.Form 83 - Part II - 424.57(d)(12).doc Form

Information Collection (IC) Details

IC Title:	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.57(d)(12)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-855S	CMS-855S	CMS-855S.Form 83 - Part II - 424.57(d)(12).doc		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	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
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	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.