Information Collection

Voluntarily Withdrawal (from the Medicare Program)

IC 240708 under ICR 202103-0938-020 · OMB 0938-1377.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	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

table that charts IC Documents
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.