Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I)

ICR 202603-0938-001

OMB: 0938-1355

Federal Form Document

IC Document Collections

IC ID	Document Title	Status
279274	Currently Enrolled via CMS-855O now Enrolling as Individual Supplier Form and Instruction	New
232330	Voluntary Termination of Medicare Enrollment Form and Instruction	Modified
232329	Reporting a Change Form and Instruction	Modified
232320	Switching Provider Type/MAC Form and Instruction	Modified
232319	Revalidation Form and Instruction	Modified
232318	Reactivation Form and Instruction	Modified
232317	Initial Enrollment Form and Instruction	Modified