Medicare Registration Application (CMS-855O)

ICR 201804-0938-024

OMB: 0938-1135

Federal Form Document

Forms and Documents
ICR Details
0938-1135 201804-0938-024
Active 201612-0938-025
Medicare Registration Application (CMS-855O)
Revision of a currently approved collection   No
Approved without change 12/03/2018
Retrieve Notice of Action (NOA) 04/26/2018
  Inventory as of this Action Requested Previously Approved
12/31/2021 36 Months From Approved 01/31/2020
95,200 0 515,200
33,600 0 243,600
0 0 0

The publication of the Patient Protection and Affordable Care Act (PPACA), section 6405 - "Physicians Who Order Items or Services Required to be Medicare Enrolled Physicians or Eligible Professionals" (regulation CMS 6010-F), contains a requirement for certain physicians and non-physician practitioners to enroll in the Medicare program for the sole purpose of ordering or referring items or services for Medicare beneficiaries. The PPACA has an effective date applicable to written orders and certifications made on or after July 1, 2010. The CMS 855O allows a physician to receive a Medicare identification number (without being approved for billing privileges) for the sole purpose of ordering and referring Medicare beneficiaries to Medicare approved providers and suppliers. This new Medicare application form allows physicians who do not provide services to Medicare beneficiaries to be given a Medicare identification number without having to supply all the data required for the submission of Medicare claims. It also allows the Medicare program to identify ordering and referring physicians without having to validate the amount of data necessary to determine claims payment eligibility (such as banking information), while continuing to identify the physician's credentials as valid for ordering and referring purposes.

PL: Pub.L. 111 - 148 6405 Name of Law: Affordable Care Act

0938-AT08 Final or interim final rulemaking 83 FR 16440 04/16/2018

  82 FR 56336 11/28/2017
83 FR 16440 04/16/2018

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 95,200 515,200 0 -420,000 0 0
Annual Time Burden (Hours) 33,600 243,600 0 -210,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Changing Regulations
CMS-4182-F rescinds the Part D enrollment requirements in 42 CFR 423.120, therefore, all references to Part D enrollment for prescribers of Part D drugs have been eliminated from this PRA package and the CMS-855O Medicare Application Form. The burden hour and cost changes are shown in the table below. As demonstrated in the following table, we have revised our burden estimates associated with Initial Enrollment Application by -420,000 respondents/responses (515,200 – 95,200) and -210,000 hours (243,600 – 33,600).

Mitch Bryman 410 786-5258 [email protected]


On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

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