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Enrolling with a Administrative Contractor (MAC)
Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)
OMB: 0938-1377
IC ID: 240712
OMB.report
HHS/CMS
OMB 0938-1377
ICR 202001-0938-007
IC 240712
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1377 can be found here:
2021-06-16 - Revision of a currently approved collection
2021-03-24 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-855B
Enrolling with a Administrative Contractor (MAC)
Form and Instruction
CMS-855B Medicare Enrollment Application with Opioid Treatment Pr
CMS-855B - Medicare Enrollment Application with Opioid Treatment Program - 30-day.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Enrolling with a Administrative Contractor (MAC)
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
New
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 424.400
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-855B
Medicare Enrollment Application with Opioid Treatment Program
CMS-855B - Medicare Enrollment Application with Opioid Treatment Program - 30-day.pdf
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
37
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Not-for-profit institutions, Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
0 %
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
37
37
0
0
0
0
Annual IC Time Burden (Hours)
74
74
0
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
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.