Change of Information Application

Medicare Enrollment Application for Eligible Ordering and Referring Physicians and Non-physician Practitioners- CMS 855O

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1135 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855(O) Change of Information Application Form and Instruction
CMS-855(O) Medicare Enrollment Application - fOr EligiblE OrdEring CMS-855O(6-30-11).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Change of Information Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855(O)	Medicare Enrollment Application - fOr EligiblE OrdEring and rEfErringPhySiCianS and nOn-PhySiCian PraCtitiOnErS	CMS-855O(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: 8,000	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 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	8,000	8,000
Annual IC Time Burden (Hours)	6,000	6,000
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.