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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

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.