Revalidation 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-855S Revalidation of enrollment information Form and Instruction
CMS-855S Medicare Durable Medical Equipment Supplier Enrollment A CMS-855S Medicare Enrollment Application DMEPOS.pdf Form and Instruction
CMS-855S 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:	Revalidation 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-855S	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: 8,099	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: 0 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	8,099	-17,857	25,956
Annual IC Time Burden (Hours)	16,198	-35,714	51,912
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.