Initial Enrollment

Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers

Documents and Forms

Document Name Document Type
Form CMS-855B Initial Enrollment Form and Instruction
CMS-855B Medicare Enrollment Application for Clinics/ Group Pract CMS-855B_112812.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Initial Enrollment	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855B	Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers	CMS-855B_112812.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,000	10,000
Annual IC Time Burden (Hours)	40,000	40,000
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.