Information Collection Request
Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I)
ICR 202301-0938-009 · OMB 0938-1355 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1355 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-855i Voluntary Termination of Medicare Enrollment |
Form and Instruction | Modified | Missing upstream |
| Form CMS-855i Reporting a Change |
Form and Instruction | Modified | Repair queued |
| Form CMS-855i Switching Provider Type/MAC |
Form and Instruction | Modified | Repair queued |
| Form CMS-855I Revalidation |
Form and Instruction | Modified | Repair queued |
| Form CMS-855i Reactivation |
Form and Instruction | Modified | Repair queued |
| Form CMS-855i Initial Enrollment |
Form and Instruction | Modified | Repair queued |
 CMS-855I Supporting Statement.docx |
Supporting Statement A | Uploaded 2023-02-28 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 232330 |  Voluntary Termination of Medicare Enrollment |
Form and Instruction | Modified | |
| 232329 | Reporting a Change |
Form and Instruction | Modified | |
| 232320 | Switching Provider Type/MAC |
Form and Instruction | Modified | |
| 232319 | Revalidation |
Form and Instruction | Modified | |
| 232318 | Reactivation |
Form and Instruction | Modified | |
| 232317 | Initial Enrollment |
Form and Instruction | Modified |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-1355 |
| Type of Information Collection | Reinstatement without change of a previously approved collection |
| Previous ICR Reference No | 201807-0938-006 |
| Agency Tracking No | CPI |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |