Medicare Enrollment Application for Institutional Providers

Medicare Enrollment Application for Institutional Providers (CMS-855A)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0685 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855A Medicare Enrollment Application for Institutional Providers Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A [Mar 2017].pdf Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A [Sept 2021].pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Enrollment Application for Institutional Providers	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855A	Medicare Enrollment Application - Institutional Providers	CMS-855A [Sept 2021].pdf		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 40,133	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: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	302,798	-1,430,602	1,733,400
Annual IC Time Burden (Hours)	97,126	-192,267	289,393
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.