Voluntary Withdrawing from Medicare

Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)

OMB: 0938-1056

IC ID: 243573

Documents and Forms
Information Collection (IC) Details

View Information Collection (IC)

Voluntary Withdrawing from Medicare
 
No New
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CM-855S Medicare Enrollment Application CMS-855S - Enrollment Application.pdf Yes Yes Fillable Fileable

Health Health Care Services

 

7 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   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 7 0 0 7 0 0
Annual IC Time Burden (Hours) 4 0 0 4 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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