Reporting Voluntary Withdrawal of Registration Information

Medicare Registration Application (CMS-855O)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1135 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855O Reporting Voluntary Withdrawal of Registration Information Form and Instruction
CMS-855O Enrollment Application CMS-855O - Medicare Registration Application.pdf Form and Instruction
CMS-855O Enrollment Application CMS-855O - Medicare Registration Application.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Reporting Voluntary Withdrawal of Registration Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

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-855O	Enrollment Application	CMS-855O - Medicare Registration Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 12,380	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: 30 %

	Approved	Program Change Due to New Statute	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	12,380	-43,620	56,000
Annual IC Time Burden (Hours)	6,190	-7,810	14,000
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.