Change of Enrollment Information

Medicare Enrollment Application (Form 855S)

OMB: 0938-1056

IC ID: 197901

Information Collection (IC) Details

View Information Collection (IC)

Change of Enrollment Information
 
No Modified
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-855-S Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 855 PECOS Screen Shots for OSORA.docx Yes No Fillable Fileable
Form and Instruction CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment Application CMS-855S(6-30-11).pdf Yes No Fillable Fileable
Form and Instruction CMS-855S Medicare Durable Medical Equipment Supplier Enrollment Application CMS-855S.pdf Yes No Fillable Fileable

Health Health Care Services

 

17,100 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   0 %

  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 17,100 0 -18,200 0 0 35,300
Annual IC Time Burden (Hours) 8,550 0 -9,100 0 0 17,650
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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