Medicare Enrollment Application for Institutional Providers (CMS-855A)

ICR 202305-0938-003

OMB: 0938-0685

Federal Form Document

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0685 can be found here:

2024-08-01 - Revision of a currently approved collection

Forms and Documents

Document Name	Status
Form CMS-855A Medicare Enrollment Application for Institutional Providers Form and Instruction	Modified
Form CMS-855A REH Completion of CMS-855A Change of Information Form and Instruction	New
CMS-855A - Responses to 60-day comments.docx Supplementary Document	2023-05-05
CMS-855A - Crosswalk Revisions Spreadsheet.xlsx Supplementary Document	2023-05-05
CMS-855A - Supporting Statement Part A (30-day).docx Supporting Statement A	2023-05-05

IC Document Collections

IC ID	Document Title	Status
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

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