Initial enrollment applications

Medicare Enrollment Application for Physician and Non-Physician Practitioners

OMB: 0938-1178

IC ID: 202859

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Initial enrollment applications
 
No New
 
Required to Obtain or Retain Benefits
 
42 CFR 424.500

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-855I Medicare Enrollment Application for Physician and Non-Physician Practitioners CMS-855I.pdf Yes No Fillable Fileable

Health Health Care Services

 

36,000 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   20 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 36,000 0 36,000 0 0 0
Annual IC Time Burden (Hours) 144,000 0 144,000 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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