Information Collection Request
Medicare Enrollment Application for Institutional Providers (CMS-855A)
ICR 202305-0938-003 · OMB 0938-0685 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0685 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form CMS-855A Medicare Enrollment Application for Institutional Providers |
Form and Instruction | Modified | Repair queued |
| Form CMS-855A REH Completion of CMS-855A Change of Information |
Form and Instruction | New | Repair queued |
 CMS-855A - Responses to 60-day comments.docx |
Supplementary Document | Uploaded 2023-05-05 | Repair queued |
 CMS-855A - Crosswalk Revisions Spreadsheet.xlsx |
Supplementary Document | Uploaded 2023-05-05 | Available |
| CMS-855A - Supporting Statement Part A (30-day).docx |
Supporting Statement A | Uploaded 2023-05-05 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 8284 |  Medicare Enrollment Application for Institutional Providers |
Form and Instruction | Modified | |
| 260074 | REH Completion of CMS-855A Change of Information |
Form and Instruction | New |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/CMS |
| OMB Control No | 0938-0685 |
| Type of Information Collection | Reinstatement with change of a previously approved collection |
| Previous ICR Reference No | 202103-0938-010 |
| Agency Tracking No | CPI |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |