Medicare Enrollment Application (Initial Enrollment)

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

Documents and Forms

Document Name Document Type
Form CMS-855B Medicare Enrollment Application (Initial Enrollment) 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
CMS-855B Enrollment Opioid Treatment Program CMS-855B - Enrollment OTP Application.pdf Form and Instruction
CMS-855B Enrollment Opioid Treatment Program CMS-855B - Enrollment OTP Application.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Enrollment Application (Initial Enrollment)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.500

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
Form and Instruction	CMS-855B	Enrollment Opioid Treatment Program	CMS-855B - Enrollment OTP Application.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15,797	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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	15,797	-23	-1,267	17,087
Annual IC Time Burden (Hours)	47,391	-69	-3,801	51,261
Annual IC Cost Burden (Dollars)	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.