Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12) New 500 250 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15) New 100 300 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4) New 67723 203169 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6) New 250 750 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9) New 250 750 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application New 9000 54000 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information New 34800 17400 0 Form CMS-855S CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information New 36667 55001 0 Form CMS-855S CMS-855S
Total burden requested under this ICR: 149290 331620 0  
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