Terminating a Reassignment

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

Documents and Forms

Document Name Document Type
Form CMS-855R Terminating a Reassignment Form
CMS-855R Reassignment of Medicare Benefits CMS-855R - Medicare Enrollment Application.pdf Form

Information Collection (IC) Details

IC Title:	Terminating a Reassignment	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:

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 49,898	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 %

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

Documents for IC

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.