Information Collection

Initial Enrollment

IC 197900 under ICR 201611-0938-010 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-855-S Initial Enrollment Form and Instruction
CMS-855S Medicare Durable Medical Equipment Supplier Enrollment A cms855s.pdf Form and Instruction
CMS-855-S Medicare Enrollment Application: Durable Medical Equipme 855 PECOS Screen Shots for OSORA.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Initial Enrollment	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855-S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	855 PECOS Screen Shots for OSORA.docx		Yes	No	Fillable Fileable
Form and Instruction	CMS-855S	Medicare Durable Medical Equipment Supplier Enrollment Application	cms855s.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,323	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	10,323	5,161	5,162
Annual IC Time Burden (Hours)	20,648	0	20,648
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.