Information Collection

Reporting Voluntary Withdrawal of Registration Information

IC 202856 under ICR 201603-0938-020 · OMB 0938-1135.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1135 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855O Reporting Voluntary Withdrawal of Registration Information	Form and Instruction
CMS-855O Medicare Registration Application CMS-855O Application Form - 508.pdf	Form and Instruction

IC Title:

Reporting Voluntary Withdrawal of Registration Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

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-855O	Medicare Registration Application	CMS-855O Application Form - 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: 56,000

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: 0 %

table that charts list of burden
	Requested	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	56,000	55,500	500
Annual IC Time Burden (Hours)	14,000	13,875	125
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.