Information Collection

Voluntarily Withdrawal (from the Medicare Program)

IC 240708 under ICR 202507-0938-001 · OMB 0938-1377.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-855B Voluntarily Withdrawal (from the Medicare Program)	Form and Instruction
Form CMS-855B Medicare Enrollment Application with Opioid Treatment Program Voluntarily Withdrawal (from the Medicare Program)	Form and Instruction
CMS-855B Medicare Enrollment Application with Opioid Treatment Pr CMS-855B - Medicare Enrollment Application with Opioid Treatment Program - 30-day.pdf	Form and Instruction
CMS-855B Medicare Enrollment Application with Opioid Treatment Pr CMS-855B - Medicare Enrollment Application with Opioid Treatment Program - 30-day.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Removed

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424,500 (To search for a specific CFR, visit the Code of Federal Regulations.)

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-855B				Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,931

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
	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-3,931	3,931
Annual IC Time Burden (Hours)	-1,966	1,966
Annual IC Cost Burden (Dollars)	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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