Information Collection

Voluntary Withdrawing from Medicare

IC 243573 under ICR 202511-0938-011 · OMB 0938-1056.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CM-855S Medicare Enrollment Application Voluntary Withdrawing from Medicare	Form and Instruction
CM-855S Medicare Enrollment Application CMS-855S Medicare Enrollment Application DMEPOS.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:

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	CM-855S				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 System

FR Citation: 83 FR 6591

Number of Respondents: 1,350

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
	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-1,350	1,350
Annual IC Time Burden (Hours)	-675	675
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.

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