Information Collection

Medicare Enrollment Applications

IC 8284 under ICR 201210-0938-009 · OMB 0938-0685.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0685 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 855B Medicare Enrollment Applications	Form and Instruction
855B Medicare Enrollment Application - Clinics/group Practice CMS-855B.pdf	Form and Instruction
855A Medicare Enrollment Application - Institutional Provider CMS-855A.pdf	Form and Instruction
855I Medicare Enrollment Application -Physicians and Non-Phys CMS-855I.pdf	Form and Instruction
855R Reassignment of Medicare Benefits CMS-855R.pdf	Form and Instruction

IC Title:

Medicare Enrollment Applications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	855B	Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers	CMS-855B.pdf	Yes	No	Fillable Fileable
Form and Instruction	855A	Medicare Enrollment Application - Institutional Providers	CMS-855A.pdf	No	No	Fillable Fileable
Form and Instruction	855I	Medicare Enrollment Application -Physicians and Non-Physician Practitioners	CMS-855I.pdf	Yes	No	Fillable Fileable
Form and Instruction	855R	Reassignment of Medicare Benefits	CMS-855R.pdf	Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,740,800

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	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,740,800	1,311,350	429,450
Annual IC Time Burden (Hours)	290,609	-565,786	856,395
Annual IC Cost Burden (Dollars)	0	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.