Information Collection

Medicare Enrollment Application for Institutional Providers

IC 8284 under ICR 202408-0938-001 · OMB 0938-0685.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855A Medicare Enrollment Application for Institutional Providers	Form and Instruction
Form CMS-855A Medicare Enrollment Application - Institutional Providers 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

IC Title:

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:

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-855A				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 %

table that charts list of burden
	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

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.

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