OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)

IC 224024 under ICR 202001-0938-004 · OMB 0938-1056.

Documents and Forms
Document Name
Document Type
Form and Instruction
Form and Instruction
Form and Instruction
Information Collection (IC) Details

View Information Collection (IC)

Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)
 
No Removed
 
Mandatory
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-855S Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 855 PECOS Screen Shots for OSORA (1).docx Yes Yes Fillable Fileable
Form and Instruction CMS-855S Medicare Durable Medical Equipment Supplier Enrollment Application cms855s.pdf No   Fillable Fileable

Health Health Care Services

 

10,666 0
   
Private Sector Businesses or other for-profits
 
   0 %

  Requested 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 0 0 0 -10,666 10,666 0
Annual IC Time Burden (Hours) 0 0 0 -42,664 42,664 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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