Information Collection

Reporting Voluntary Withdrawal of Registration Information

IC 202856 under ICR 202509-0938-024 · OMB 0938-1135.

Documents and Forms

Document Name Document Type
Form CMS-855O Enrollment Application Reporting Voluntary Withdrawal of Registration Information Form and Instruction
CMS-855O Enrollment Application CMS-855O - Medicare Registration Application.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Reporting Voluntary Withdrawal of Registration 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-855O	Enrollment Application	CMS-855O - Medicare Registration Application.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 6,190	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: 30 %

	Requested	Previously Approved
Annual Number of Responses for this IC	6,190	6,190
Annual IC Time Burden (Hours)	3,095	3,095
Annual IC Cost Burden (Dollars)	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.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].