Information Collection

Reporting Voluntary Withdrawal of Registration Information

IC 202856 under ICR 201206-0938-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
CMS-855O.Screenshots.docx Other-Screen Shots
CMS-855O Medicare Registration Application CMS-855O_Draft_Form.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reporting Voluntary Withdrawal of Registration Information	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
Other-Screen Shots			CMS-855O.Screenshots.docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-855O	Medicare Registration Application	CMS-855O_Draft_Form.pdf		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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	125	125
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.