Voluntary Withdrawing from Medicare

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

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1056 can be found here:

Documents and Forms

Document Name Document Type
Form CM-855S Voluntary Withdrawing from Medicare Form and Instruction
CM-855S Medicare Enrollment Application CMS-855S - Medicare Enrollment Application - OMB.pdf Form and Instruction
CM-855S Medicare Enrollment Application CMS-855S - Medicare Enrollment Application - OMB.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Voluntary Withdrawing from Medicare	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	CM-855S	Medicare Enrollment Application	CMS-855S - Medicare Enrollment Application - OMB.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 7	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	7	7
Annual IC Time Burden (Hours)	4	4
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.