Skip to main content
An official website of the United States government
The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.
The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
Search:
Agenda
Reg Review
ICR
This script is used to control the display of information in this page.
Display additional information by clicking on the following:
All
Brief and OIRA conclusion
Abstract/Justification
Legal Statutes
Rulemaking
FR Notices/Comments
IC List
Burden
Misc.
Common Form Info.
Certification
View Information Collection (IC) List
View Supporting Statement and Other Documents
Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0685
ICR Reference No:
200711-0938-002
Status:
Historical Active
Previous ICR Reference No:
200602-0938-007
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Medicare Enrollment Application
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
02/22/2008
Retrieve Notice of Action (NOA)
Date Received in OIRA:
11/15/2007
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/28/2011
36 Months From Approved
04/30/2009
Responses
400,000
0
400,000
Time Burden (Hours)
1,001,503
0
1,000,000
Cost Burden (Dollars)
0
0
0
Abstract:
The Medicare enrollment application is used to gather information from providers and suppliers to participate in the Medicare program and to furnish services to Medicare beneficiaries. The information submitted is used uniquely to identify the providers and suppliers for the prupose of enumeration and payment.
Authorizing Statute(s):
US Code:
42 USC 1395f
Name of Law: Conditions of and Limitations on Payment for Services
US Code:
42 USC 1395g
Name of Law: Payment to Providers of Services
PL:
Pub.L. 105 - 33 4313
Name of Law: Provision of certain identification numbers
US Code:
42 USC 1395l
Name of Law: Payment of Benefits
US Code:
42 USC 1395u
Name of Law: Provisions related to the Administration of Part B
US Code:
42 USC 1395m
Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
US Code:
42 USC 1395cc
Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
PL:
Pub.L. 104 - 134 31001(I)
Name of Law: Debt Collection Improvement Act of 1996
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
72 FR 26819
05/11/2007
30-day Notice:
Federal Register Citation:
Citation Date:
72 FR 58096
10/12/2007
Did the Agency receive public comments on this ICR?
Yes
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Medicare Enrollment Application
CMS-855A, CMS-855B, CMS-855I, CMS-855R, CMS-855S
CMS-855A
,
CMS-855B
,
CMS-855I
,
CMS-855R
,
CMS-855S
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
400,000
400,000
0
0
0
0
Annual Time Burden (Hours)
1,001,503
1,000,000
0
1,503
0
0
Annual Cost Burden (Dollars)
0
0
0
0
0
0
Burden increases because of Program Change due to Agency Discretion:
Yes
Burden Increase Due to:
Miscellaneous Actions
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
The burden increased slightly based on the revisions to the instruments CMS-855A and the CMS-855B.
Annual Cost to Federal Government:
$0
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
Uncollected
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
Uncollected
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
Uncollected
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
William Parham 4107864669
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
11/15/2007
An official website of the United States government
The .gov means it's official.
The site is secure.
