Medicare Enrollment Applications

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

OMB: 0938-0685

IC ID: 8284

Information Collection (IC) Details

View Information Collection (IC)

Medicare Enrollment Applications
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

1,786,732 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   0 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 1,786,732 0 53,332 0 0 1,733,400
Annual IC Time Burden (Hours) 513,435 0 224,044 0 0 289,391
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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