Medicare Enrollment Application for Physician and Non-Physician Practitioners; (CMS-855i)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855i Voluntary Termination of Medicare Enrollment	Form and Instruction	New	Available
Form CMS-855i Reporting a Change of Medicare Enrollment Information	Form and Instruction	New	Available
Form CMS-855i Switching Provider Type/MAC	Form and Instruction	New	Available
Form CMS-855I Revalidation	Form and Instruction	New	Available
Form CMS-855i Reactivation	Form and Instruction	New	Available
Form CMS-855i Initial Enrollment	Form and Instruction	New	Available
CMS-855I Supporting Statement 60-day NEW 72518.docx	Supporting Statement A	Uploaded 2018-07-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
232330	Voluntary Termination of Medicare Enrollment	Form and Instruction	New
232329	Reporting a Change of Medicare Enrollment Information	Form and Instruction	New
232320	Switching Provider Type/MAC	Form and Instruction	New
232319	Revalidation	Form and Instruction	New
232318	Reactivation	Form and Instruction	New
232317	Initial Enrollment	Form and Instruction	New

ICR Details

OMB Control No: 0938-1355	ICR Reference No: 201807-0938-006
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application for Physician and Non-Physician Practitioners; (CMS-855i)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/06/2018
	Date Received in OIRA: 08/02/2018
Terms of Clearance: Upon approval, CMS will submit a change request to update OMB control number 0938-0685 to remove the CMS-855I application from that Medicare application bundle ICR.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	36 Months From Approved
Responses	513,872	0	0
Time Burden (Hours)	1,000,167	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The primary function of the CMS-855I Medicare enrollment application for physicians and non-physician practitioners is to gather information from an individual provider or supplier that tells us who he/she is, whether he/she meets certain qualifications to be a Medicare health care provider or supplier, where he/she practices or renders services, and other information necessary to establish correct claims payments.

---

Authorizing Statute(s): PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.500 Name of Law: Requirements for Establishing and Maintaining Medicare Billing Privileges
   US Code: 42 USC 424.502 Name of Law: Definitions
   US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number
   US Code: 5 USC 522(b)(4) Name of Law: The Freedom of Information Act
   US Code: 26 USC 501(c) Name of Law: List of Tax Exempt Organizations
   US Code: 26 USC 3402(t) Name of Law: Income Tax Collected At Source
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 10730	03/12/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 32667	07/13/2018
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Initial Enrollment	CMS-855i	Medicare Enrollment Application
Reactivation	CMS-855i	Medicare Enrollment Application
Revalidation	CMS-855I	Medicare Enrollment Application
Switching Provider Type/MAC	CMS-855i	Medicare Enrollment Application
Reporting a Change of Medicare Enrollment Information	CMS-855i	Medicare Enrollment Application
Voluntary Termination of Medicare Enrollment	CMS-855i	Medicare Enrollment Application

---

ICR Summary of Burden

table that charts list of burden

	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	513,872	0	0	513,872	0	0
Annual Time Burden (Hours)	1,000,167	0	0	1,000,167	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information. The burden hours associated with this data collection is 1,000,167 hours.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 08/02/2018

---