Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Change of Enrollment Information Unchanged 55650 55650 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Enrolling with a Administrative Contractor (MAC) Unchanged 37 74 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Home Infusion Therapy (HIT) Supplier Enrollment Unchanged 700 1750 0 Form and Instruction CMS-855B Medicare Enrollment Application
Medicare Enrollment Application (Initial Enrollment) Unchanged 17087 51261 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Form and Instruction CMS-855B Enrollment Opioid Treatment Program
Medicare Enrollment Application (Reactivation) Unchanged 1316 2632 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Plan
Medicare Enrollment Application - Revalidation Unchanged 31211 62422 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Voluntarily Withdrawal (from the Medicare Program) Unchanged 3931 1966 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Total burden requested under this ICR: 109932 175755 0  
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