Medicare Enrollment Applications

Medicare Enrollment Applications (CMS-855A, B, and I)

⚠️ Notice: This information collection may be referencing outdated material.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 CMS-855A Medicare Enrollment Applications Form and Instruction
CMS-855B Medicare Enrollment Application - Clinics/Group Practice CMS-855B [Mar 2017].pdf Form and Instruction
CMS-855I Medicare Enrollment Application - Physicians and Non-Phy CMS-855I [Mar 2017].pdf Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A [Mar 2017].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	CMS-855A	Medicare Enrollment Application - Institutional Providers	CMS-855A [Mar 2017].pdf	Yes	No	Fillable Fileable Signable
Form and Instruction	CMS-855B	Medicare Enrollment Application - Clinics/Group Practices and Certain Other Suppliers	CMS-855B [Mar 2017].pdf	Yes	No	Fillable Fileable
Form and Instruction	CMS-855I	Medicare Enrollment Application - Physicians and Non-Physician Practitioners	CMS-855I [Mar 2017].pdf	Yes	No	Fillable Fileable

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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	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.