Information Collection

Reactivation - Medicare Enrollment Application

IC 243574 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-855S Reactivation - Medicare Enrollment Application Form and Instruction
CMS-855S Medicare Enrollment Application CMS-855S Medicare Enrollment Application DMEPOS.pdf Form and Instruction
CMS-855S Medicare Enrollment Application CMS-855S Medicare Enrollment Application DMEPOS.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reactivation - Medicare Enrollment Application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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 Enrollment Application	CMS-855S Medicare Enrollment Application DMEPOS.pdf		Yes	Yes	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 System83	FR Citation: 83 FR 6591

Number of Respondents: 2,508	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	2,508	132	2,376
Annual IC Time Burden (Hours)	10,032	520	9,512
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.