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:
0938-1056
ICR Reference No:
200810-0938-001
Status:
Historical Active
Previous ICR Reference No:
Agency/Subagency:
HHS/CMS
Agency Tracking No:
Title:
Medicare Enrollment Application (Form 855S)
Type of Information Collection:
New collection (Request for a new OMB Control Number)
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved with change
Conclusion Date:
03/16/2009
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/01/2008
Terms of Clearance:
This ICR is approved consistent with revised supporting statement and burden estimates.
Inventory as of this Action
Requested
Previously Approved
Expiration Date
03/31/2012
36 Months From Approved
Responses
149,290
0
0
Time Burden (Hours)
331,620
0
0
Cost Burden (Dollars)
0
0
0
Abstract:
The primary function of the CMS 855S DMEPOS supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855S DMEPOS supplier enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. Additionally, periodic revisions are necessary to incorporate new regulatory requirements. CMS is also revising the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685) to remove the CMS-855S application from its collection.
Authorizing Statute(s):
US Code:
42 USC 1395f
Name of Law: Requirements of Requests and Certifications
US Code:
42 USC 1395g
Name of Law: Requirements of Requests and Certifications
US Code:
42 USC 1395cc
Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
US Code:
42 USC 1395m
Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
PL:
Pub.L. 105 - 33 4313
Name of Law: Balanced Budget Act of 1997
PL:
Pub.L. 104 - 134 31001(I)
Name of Law: Debt Collection Improvement Act of 1996
US Code:
42 USC 1395l
Name of Law: Payment of Benefits
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:
73 FR 31120
05/30/2008
30-day Notice:
Federal Register Citation:
Citation Date:
73 FR 49677
08/22/2008
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
8
IC Title
Form No.
Form Name
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12)
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15)
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4)
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6)
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9)
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information
CMS-855S
CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information
CMS-855S
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
149,290
0
0
149,290
0
0
Annual Time Burden (Hours)
331,620
0
0
331,620
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:
This is a new collection. Previously the form CMS-855S was associated with the OMB control number 0938-0685. However, we are seeking a new number for only the CMS-855S.
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:
10/01/2008
An official website of the United States government
The .gov means it's official.
The site is secure.
