Change of Enrollment Information

Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)

Documents and Forms

Document Name Document Type
Form CMS-855(S) Change of Enrollment Information Form and Instruction
CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment A CMS-855S Medicare Enrollment Application DMEPOS.pdf Form and Instruction
CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment A CMS-855S Medicare Enrollment Application DMEPOS.pdf Form and Instruction
CMS-855-S Medicare Enrollment Application: Durable Medical Equipme CMS- 855S - DMEPOS Supplier PECOS Screen Shots - Word - 508.pdf Form and Instruction
CMS-855-S Medicare Enrollment Application: Durable Medical Equipme CMS- 855S - DMEPOS Supplier PECOS Screen Shots - Word - 508.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Change of Enrollment Information	Agency IC Tracking Number:

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-855(S)	Medicare Durable Medical Equipment Supplier Enrollment Application	CMS-855S Medicare Enrollment Application DMEPOS.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-855-S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	CMS- 855S - DMEPOS Supplier PECOS Screen Shots - Word - 508.pdf		Yes	No	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: 09-70-0532 - The Provider Enrollment, Chain and Ownership System	FR Citation: 83 FR 6591

Number of Respondents: 14,117	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: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	14,117	2,012	12,105
Annual IC Time Burden (Hours)	14,117	2,012	12,105
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.