Terminating a Reassignment

Medicare Enrollment Application- Reassignment of Medicare Benefits (CMS-855R)

OMB: 0938-1179

IC ID: 202867

Information Collection (IC) Details

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Terminating a Reassignment
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 424.500

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form CMS-855R Reassignment of Medicare Benefits CMS-855R - Medicare Enrollment Application.pdf Yes No Fillable Printable

Health Health Care Services

 

49,898 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   30 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 49,898 0 0 6,023 43,875 0
Annual IC Time Burden (Hours) 12,475 0 0 1,506 10,969 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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