Voluntarily Withdrawal (from the Medicare Program)

Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers (CMS-855B)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1377 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855B Voluntarily Withdrawal (from the Medicare Program) 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
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

IC Title:	Voluntarily Withdrawal (from the Medicare Program)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424,500 (To search for a specific CFR, visit the Code of Federal Regulations.)

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 Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,931	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	Previously Approved
Annual Number of Responses for this IC	3,931	3,931
Annual IC Time Burden (Hours)	1,966	1,966
Annual IC Cost Burden (Dollars)	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.