Change of Enrollment Information

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

Documents and Forms

Document Name Document Type
Form CMS-855B Change of Enrollment Information 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:	Change of Enrollment Information	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

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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 55,650	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	Previously Approved
Annual Number of Responses for this IC	55,650	55,650
Annual IC Time Burden (Hours)	55,650	55,650
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.