Information Collection

Voluntary Withdrawing from Medicare

IC 243573 under ICR 202201-0938-015 · OMB 0938-1056.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.