Terminating a Reassignment

Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form CMS-855R Terminating a Reassignment Form
CMS-855R Reassignment of Medicare Benefits CMS-855R - REASSIGNMENT OF MEDICARE BENEFITS Application.pdf Form

Information Collection (IC) Details

IC Title:	Terminating a Reassignment	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-855R	Reassignment of Medicare Benefits	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: 43,875	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	43,875	-56,125	100,000
Annual IC Time Burden (Hours)	10,969	-14,031	25,000
Annual IC Cost Burden (Dollars)	0	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.