Information Collection

Change of Enrollment Information

IC 197901 under ICR 201512-0938-004 · OMB 0938-1056.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1056 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855(S) Change of Enrollment Information Form and Instruction
CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment A CMS-855S - Medical Enrollment Application.pdf Form and Instruction
CMS-855-S Medicare Enrollment Application: Durable Medical Equipme CMS- 855S - DMEPOS Supplier PECOS Screen Shots - Word - 508.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Change of Enrollment Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855(S)	Medicare Durable Medical Equipment Supplier Enrollment Application	CMS-855S - Medical Enrollment Application.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-855-S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	CMS- 855S - DMEPOS Supplier PECOS Screen Shots - Word - 508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 68,681	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 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	68,681	51,581	17,100
Annual IC Time Burden (Hours)	17,171	8,621	8,550
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.