Information Collection

REH Completion of CMS-855A Change of Information

IC 260074 under ICR 202305-0938-003 · OMB 0938-0685.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855A REH Completion of CMS-855A Change of Information	Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A (Medicare Enrollment Application - Institutional Providers).pdf	Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A-(Medicare Enrollment Application - Institutional Providers ).pdf	Form and Instruction

IC Title:

REH Completion of CMS-855A Change of Information

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855A	Medicare Enrollment Application - Institutional Providers	CMS-855A-(Medicare Enrollment Application - Institutional Providers ).pdf		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	23	23
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.