Initial Application

Medicare Registration Application (CMS-855O)

Documents and Forms

Document Name Document Type
Form CMS-855O Initial Application Form and Instruction
CMS-855O Enrollment Application CMS-855O - Medicare Registration Application.pdf Form and Instruction
CMS-855O Enrollment Application CMS-855O - Medicare Registration Application.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Initial Application	Agency IC Tracking Number:	CPI - 855O

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855O	Enrollment Application	CMS-855O - Medicare Registration Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: Provider Enrollment, Chain and Ownership System (PECOS), number 09-70-0532.	FR Citation: 71 FR 60536

Number of Respondents: 45,822	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: 50 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	45,822	14,226	31,596
Annual IC Time Burden (Hours)	22,911	7,113	15,798
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.