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⚠️ Notice: This information collection may be referencing outdated material.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: 1,786,732	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	1,786,732	53,332	1,733,400
Annual IC Time Burden (Hours)	513,435	224,044	289,391
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.