Information Collection

Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)

IC 224024 under ICR 201610-0938-004 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855S Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)	Form and Instruction
CMS-855S Medicare Durable Medical Equipment Supplier Enrollment A CMS-855S - Medical Enrollment Application.pdf	Form and Instruction
CMS-855S Medicare Enrollment Application: Durable Medical Equipme 855 PECOS Screen Shots for OSORA (1).docx	Form and Instruction

IC Title:

Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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-855S	Medicare Durable Medical Equipment Supplier Enrollment Application	CMS-855S - Medical Enrollment Application.pdf		No		Fillable Fileable
Form and Instruction	CMS-855S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	855 PECOS Screen Shots for OSORA (1).docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10,666

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	10,666	10,666
Annual IC Time Burden (Hours)	63,996	63,996
Annual IC Cost Burden (Dollars)	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.