Voluntary Termination of Medicare Enrollment

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

OMB: 0938-1355

IC ID: 232330

Information Collection (IC) Details

View Information Collection (IC)

Voluntary Termination of Medicare Enrollment
 
No Modified
 
Required to Obtain or Retain Benefits
 
42 CFR 424.500

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

Health Health Care Services

 

17,767 0
   
Private Sector Not-for-profit institutions, Businesses or other for-profits
 
   36 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 17,767 0 0 -24,325 42,092 0
Annual IC Time Burden (Hours) 8,884 0 0 -12,162 21,046 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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