Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Change of Enrollment Information Modified 78489 78489 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Enrolling with a Administrative Contractor (MAC) Modified 37 74 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Home Infusion Therapy (HIT) Supplier Enrollment Removed 0 0 0 Form and Instruction CMS-855B Medicare Enrollment Application
Medicare Enrollment Application (Initial Enrollment) Modified 42083 126249 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) Modified 5761 11522 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Plan
Medicare Enrollment Application - Revalidation Modified 41608 83216 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Voluntarily Withdrawal (from the Medicare Program) Removed 0 0 0 Form and Instruction CMS-855B Medicare Enrollment Application with Opioid Treatment Program
Total burden requested under this ICR: 167978 299550 0  
To view an IC, click on IC Title