Voluntary Termination of Medicare Enrollment

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

Documents and Forms

Document Name Document Type
Form CMS-855i Voluntary Termination of Medicare Enrollment 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:	Voluntary Termination of Medicare Enrollment	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: 17,767	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: 36 %

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