Medicare Enrollment Applications

Medicare Enrollment Application (CMS-855ABI)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0685 can be found here:

Documents and Forms

Document Name Document Type
Form 855B Medicare Enrollment Applications Form and Instruction
855B Medicare Enrollment Application - Clinics/group Practice CMS-855B.pdf Form and Instruction
855I Medicare Enrollment Application -Physicians and Non-Phys CMS-855I.pdf Form and Instruction
CMS-855 Medicare Enrollment Application CMS-855A (REVISED).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Enrollment Applications	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	855B	Medicare Enrollment Application - Clinics/group Practices and Certain Other Suppliers	CMS-855B.pdf	Yes	No	Fillable Fileable
Form and Instruction	855I	Medicare Enrollment Application -Physicians and Non-Physician Practitioners	CMS-855I.pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-855	Medicare Enrollment Application	CMS-855A (REVISED).pdf	Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,733,400	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	1,733,400	-7,400	1,740,800
Annual IC Time Burden (Hours)	289,391	-1,218	290,609
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.