View Information Collection (IC)

View Information Collection (IC)

IC Title:	Revalidation of enrollment 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-855S	Medicare Durable Medical Equipment Supplier Enrollment Application	CMS-855S Medicare Enrollment Application DMEPOS.pdf		Yes	No	Fillable Fileable
Form and Instruction	CMS-855-S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	CMS- 855S - DMEPOS Supplier PECOS Screen Shots - Word - 508.pdf		Yes	No	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

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: 8,099	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 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	8,099	0	0	-17,857	0	25,956
Annual IC Time Burden (Hours)	16,198	0	0	-35,714	0	51,912
Annual IC Cost Burden (Dollars)	0	0	0	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.