Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Adding Information (New Business Data) New 1242 1242 0 Form and Instruction CMS-855S
Change of Enrollment Information Modified 12105 12105 0 Form and Instruction CMS-855(S)
Form and Instruction CMS-855-S
Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222) Removed 0 0 0 Form and Instruction CMS-855S
Form and Instruction CMS-855S
Initial Enrollment Modified 3429 13716 0 Form and Instruction CMS-855S
Form and Instruction CMS-855-S
Reactivation - Medicare Enrollment Application New 2376 9512 0 Form and Instruction CMS-855S
Revalidation of enrollment information Modified 25956 51912 0 Form and Instruction CMS-855S
Form and Instruction CMS-855-S
Voluntary Withdrawing from Medicare New 7 4 0 Form and Instruction CM-855S
Total burden requested under this ICR: 45115 88491 0  
To view an IC, click on IC Title