Information Collection

Establishing a reassignment of benefits enrollment application

IC 202866 under ICR 201206-0938-007 · OMB 0938-1179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1179 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855R Establishing a reassignment of benefits enrollment application	Form and Instruction
CMS-855R Reassignment of Medicare Benefits CMS-855R - 01122012.PDF	Form and Instruction

IC Title:

Establishing a reassignment of benefits enrollment application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.500

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-855R	Reassignment of Medicare Benefits	CMS-855R - 01122012.PDF		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100,000

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: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100,000	100,000
Annual IC Time Burden (Hours)	25,000	25,000
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.