Information Collection

Reporting a Change of Medicare Enrollment Information

IC 232329 under ICR 201807-0938-006 · OMB 0938-1355.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1355 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855i Reporting a Change of Medicare Enrollment Information	Form and Instruction
CMS-855i Medicare Enrollment Application CMS-855I - Medicare Enrollment Application.docx	Form and Instruction

IC Title:

Reporting a Change of Medicare Enrollment Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.500

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-855i	Medicare Enrollment Application	CMS-855I - Medicare Enrollment Application.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 127,416

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	127,416	127,416
Annual IC Time Burden (Hours)	127,416	127,416
Annual IC Cost Burden (Dollars)	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.