Information Collection

Establishing or adding a reassignment of benefits enrollment application

IC 202866 under ICR 201509-0938-008 · 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⚠️ Notice: This information collection may be referencing outdated material.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-855-R Reasignment of Medicare Benefits Application Establishing or adding a reassignment of benefits enrollment application	Form and Instruction
CMS-855-R Reasignment of Medicare Benefits Application CMS-855R - REASSIGNMENT OF MEDICARE BENEFITS Application.pdf	Form and Instruction

IC Title:

Establishing or adding a reassignment of benefits enrollment application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-855-R	Reasignment of Medicare Benefits Application	CMS-855R - REASSIGNMENT OF MEDICARE BENEFITS Application.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 335,744

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: 30 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	335,744	235,744	100,000
Annual IC Time Burden (Hours)	83,936	58,936	25,000
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.