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⚠️ Notice: This information collection may be referencing outdated material.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-855B 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

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-855B	Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers	CMS-855B(6-30-11).pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-855(I)	Medicare Enrollment Application -Physicians and Non-Physician Practitioners	CMS-855I(6-30-11).pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-855(R)	Medicare Enrollment Application -REASSIGNMENT OF MEDICARE BENEFITS	CMS-855R(6-30-11).pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-855A	Medicare Enrollment Application - Institutional Providers	CMS-855A(6-30-11).pdf	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: 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	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

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.