Information Collection

Change of Information Application

IC 197862 under ICR 201105-0938-013 · OMB 0938-1135.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.