Reporting Voluntary Withdrawal of Registration Information

Medicare Registration Application (CMS-855O)

OMB: 0938-1135

IC ID: 202856

Information Collection (IC) Details

View Information Collection (IC)

Reporting Voluntary Withdrawal of Registration Information
 
No Modified
 
Mandatory
 

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

Health Health Care Services

 

12,380 0
   
Private Sector Businesses or other for-profits, Not-for-profit institutions
 
   30 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 12,380 -43,620 0 0 56,000 0
Annual IC Time Burden (Hours) 6,190 -7,810 0 0 14,000 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.

© 2024 OMB.report | Privacy Policy