Reporting a Change

Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I)

Documents and Forms

Document Name Document Type
Form CMS-855i Reporting a Change Form and Instruction
CMS-855i Medicare Enrollment Application CMS-855I - Medicare Enrollment Application.docx Form and Instruction
CMS-855i Medicare Enrollment Application CMS-855I - Medicare Enrollment Application.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Reporting a Change	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.500

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855i	Medicare Enrollment Application	CMS-855I - Medicare Enrollment Application.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 485,734	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	485,734	358,318	127,416
Annual IC Time Burden (Hours)	491,924	364,508	127,416
Annual IC Cost Burden (Dollars)	0	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.