Information Collection Request

Medicare Registration Application (CMS-855O)

ICR 201603-0938-020 · OMB 0938-1135 · Historical Inactive

Forms and Documents

Forms and supporting documents for this ICR
DocumentTypeStatusAvailability
Form CMS-855O Reporting Voluntary Withdrawal of Registration Information Form and Instruction Modified Repair queued
Form CMS-855O Change of Registration Information Form and Instruction Modified Available
Form CMS-855O Initial Application Form and Instruction Modified Repair queued
CMS 855O - Revisons Spreadsheet - 01042012.xlsx Supplementary Document Uploaded 2012-06-22 Available
CMS-855O Supporting Statement - u.pdf Supporting Statement A Uploaded 2016-03-28 Available

IC Document Collections

Information collection document groups
IC IDCollectionTypeStatusForm
202856 Reporting Voluntary Withdrawal of Registration Information Form and Instruction Modified
197862 Change of Registration Information Form and Instruction Modified
197861 Initial Application Form and Instruction Modified

ICR Details

Reginfo record details
table that charts list comparision
  Inventory as of this Action Requested Previously Approved
36 Months From Approved
0 0 0
0 0 0
0 0 0





Reginfo record details
3
table that charts list of burden
IC Title Form No. Form Name
Change of Registration Information CMS-855O Medicare Registration Application
Initial Application CMS-855O Medicare Registration Application
Reporting Voluntary Withdrawal of Registration Information CMS-855O Medicare Registration Application



Reginfo record details
  No