Information Collection

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

IC 188181 under ICR 201105-0938-016 · OMB 0938-1056.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

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

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	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 %

table that charts list of burden
	Program Change Due to Agency Discretion	Previously Approved
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

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.