Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Establishing or adding a reassignment of benefits enrollment application Modified 335744 83936 0 Form and Instruction CMS-855-R
Terminating a Reassignment Modified 43875 10969 0 Form CMS-855R
Total burden requested under this ICR: 379619 94905 0  
To view an IC, click on IC Title