Information Collection

Revalidation

IC 232319 under ICR 202603-0938-001 · OMB 0938-1355.

Documents and Forms

Document Name Document Type
Form CMS-855I Medicare Enrollment Application Revalidation Form and Instruction
CMS-855I Medicare Enrollment Application CMS 855 I.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Revalidation	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.500

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855I	Medicare Enrollment Application	CMS 855 I.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 101,890	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 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	101,890	0	101,890
Annual IC Time Burden (Hours)	206,494	2,714	203,780
Annual IC Cost Burden (Dollars)	0	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.

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