Information Collection

Medicare Enrollment Application

IC 8284 under ICR 201105-0938-012 · 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⚠️ Notice: This information collection may be referencing outdated material.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-855B Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers Medicare Enrollment Application	Form and Instruction
Form CMS-855(I) Medicare Enrollment Application -Physicians and Non-Physician Practitioners Medicare Enrollment Application	Form and Instruction
Form CMS-855(R) Medicare Enrollment Application -REASSIGNMENT OF MEDICARE BENEFITS Medicare Enrollment Application	Form and Instruction
Form CMS-855A Medicare Enrollment Application - Institutional Providers Medicare Enrollment Application	Form and Instruction
CMS-855B Medicare Enrollment Application - Clinics/group Practice CMS-855B(6-30-11).pdf	Form and Instruction
CMS-855(I) Medicare Enrollment Application -Physicians and Non-Phys CMS-855I(6-30-11).pdf	Form and Instruction
CMS-855(R) Medicare Enrollment Application -REASSIGNMENT OF MEDICAR CMS-855R(6-30-11).pdf	Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A(6-30-11).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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855B	Yes	No	Fillable Fileable
Form and Instruction	CMS-855(I)	Yes	No	Fillable Fileable
Form and Instruction	CMS-855(R)	Yes	No	Fillable Fileable
Form and Instruction	CMS-855A	Yes	No	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: Businesses or other for-profits, Not-for-profit institutions

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	429,450	29,450	400,000
Annual IC Time Burden (Hours)	856,395	70,693	785,702
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.

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