Information Collection

Establishing or adding a reassignment of benefits enrollment application

IC 202866 under ICR 201906-0938-008 · OMB 0938-1179.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855-R Establishing or adding a reassignment of benefits enrollment application	Form and Instruction
CMS-855-R Reasignment of Medicare Benefits Application CMS-855R - Medicare Enrollment Application.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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-855-R	Reasignment of Medicare Benefits Application	CMS-855R - Medicare Enrollment Application.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 307,730

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: 30 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	307,730	-28,014	335,744
Annual IC Time Burden (Hours)	76,933	-7,003	83,936
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.