Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-855S Medicare Enrollment Application	Form and Instruction	Modified	Available
Form CMS-855S Adding Information (New Business Data)	Form and Instruction	Modified	Repair queued
Form CMS-855S Medicare Enrollment Application	Form and Instruction	Modified	Available
Form CMS-855S Reactivation - Medicare Enrollment Application	Form and Instruction	Modified	Repair queued
Form CM-855S Medicare Enrollment Application	Form and Instruction	Modified	Available
Form CM-855S Voluntary Withdrawing from Medicare	Form and Instruction	Modified	Repair queued
Form CMS-855-S Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	Form and Instruction	Modified	Available
Form CMS-855S Medicare Durable Medical Equipment Supplier Enrollment Application	Form and Instruction	Modified	Available
Form CMS-855S Revalidation of enrollment information	Form and Instruction	Modified	Repair queued
Form CMS-855-S Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	Form and Instruction	Modified	Available
Form CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment Application	Form and Instruction	Modified	Available
Form CMS-855(S) Change of Enrollment Information	Form and Instruction	Modified	Repair queued
Form CMS-855-S Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	Form and Instruction	Modified	Available
Form CMS-855S Medicare Durable Medical Equipment Supplier Enrollment Application	Form and Instruction	Modified	Available
Form CMS-855S Initial Enrollment	Form and Instruction	Modified	Repair queued
CMS-855S - Non-Sub Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-01-11	Repair queued
CMS-855S - SPPG Statement Final (10-18-21).docx	Supporting Statement A	Uploaded 2021-10-19	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
243576	Adding Information (New Business Data)	Form and Instruction	Modified	Medicare Enrollment Application
243576	Adding Information (New Business Data)	Form and Instruction	Modified
243574	Reactivation - Medicare Enrollment Application	Form and Instruction	Modified	Medicare Enrollment Application
243574	Reactivation - Medicare Enrollment Application	Form and Instruction	Modified
243573	Voluntary Withdrawing from Medicare	Form and Instruction	Modified	Medicare Enrollment Application
243573	Voluntary Withdrawing from Medicare	Form and Instruction	Modified
197902	Revalidation of enrollment information	Form and Instruction	Modified	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
197902	Revalidation of enrollment information	Form and Instruction	Modified	Medicare Durable Medical Equipment Supplier Enrollment Application
197902	Revalidation of enrollment information	Form and Instruction	Modified
197901	Change of Enrollment Information	Form and Instruction	Modified	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
197901	Change of Enrollment Information	Form and Instruction	Modified	Medicare Durable Medical Equipment Supplier Enrollment Application
197901	Change of Enrollment Information	Form and Instruction	Modified
197900	Initial Enrollment	Form and Instruction	Modified	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
197900	Initial Enrollment	Form and Instruction	Modified	Medicare Durable Medical Equipment Supplier Enrollment Application
197900	Initial Enrollment	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1056	ICR Reference No: 202201-0938-015
Status: Historical Active	Previous ICR Reference No: 202001-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/12/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/11/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2024	10/31/2024	10/31/2024
Responses	45,115	0	45,115
Time Burden (Hours)	88,491	0	88,491
Cost Burden (Dollars)	0	0	0

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Abstract: The primary function of the CMS 855S Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish correct claims payment. The goal of this revision of the CMS 855S is to simplify and clarify the current data collection and to remove obsolete and/or redundant questions. Grammar and spelling errors were corrected. Limited informational text has been added within the application form and instructions in conjunction with links to websites when greater detail is needed by the supplier. To clarify current data collection differentiations and to be in sync with accreditation coding, Section 3D (“Products and Services Furnished by This Supplier”) has been updated. This revision does not offer any new material data collection.

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Authorizing Statute(s): US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.57 Name of Law: DMEPOS Supplier Standards
   US Code: 42 USC 455.460 Name of Law: Application fee
   PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   US Code: 42 USC 424.58 Name of Law: DMEPOS Supplier Accreditation Requirements
   PL: Pub.L. 111 - 148 6201(3) Name of Law: Required Fingerprint Check as Part of Criminal History Background Check
   US Code: 42 USC 3004(b)(1) Name of Law: Public Health Service Act
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
   US Code: 42 USC 1395f Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395g Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 32924	07/10/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 65396	11/27/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Adding Information (New Business Data)	CMS-855S	Medicare Enrollment Application
Change of Enrollment Information	CMS-855(S), CMS-855-S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Initial Enrollment	CMS-855-S, CMS-855S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Reactivation - Medicare Enrollment Application	CMS-855S	Medicare Enrollment Application
Revalidation of enrollment information	CMS-855S, CMS-855-S	Medicare Durable Medical Equipment Supplier Enrollment Application ,   Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
Voluntary Withdrawing from Medicare	CM-855S	Medicare Enrollment Application

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45,115	45,115	0	0	0	0
Annual Time Burden (Hours)	88,491	88,491	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/11/2022

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