Information Collection

Change of Enrollment Information

IC 197901 under ICR 202309-0938-006 · OMB 0938-1056.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1056 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855(S) Change of Enrollment Information	Form and Instruction
Form CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment Application Change of Enrollment Information	Form and Instruction
Form CMS-855-S Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers 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

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:

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-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 %

table that charts list of burden
	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

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.