Medicare Enrollment Application for Institutional Providers

Medicare Enrollment Application for Institutional Providers (CMS-855A)

Documents and Forms

Document Name Document Type
Form CMS-855A Medicare Enrollment Application for Institutional Providers Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A-(Medicare Enrollment Application - Institutional Providers ).pdf Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A-(Medicare Enrollment Application - Institutional Providers ).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Medicare Enrollment Application for Institutional Providers	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-855A	Medicare Enrollment Application - Institutional Providers	CMS-855A-(Medicare Enrollment Application - Institutional Providers ).pdf		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 424,069	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	424,069	206,599	217,470
Annual IC Time Burden (Hours)	117,105	75,985	41,120
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.