View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0938-1355	ICR Reference No: 201807-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application for Physician and Non-Physician Practitioners; (CMS-855i)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/06/2018
	Date Received in OIRA: 08/02/2018
Terms of Clearance: Upon approval, CMS will submit a change request to update OMB control number 0938-0685 to remove the CMS-855I application from that Medicare application bundle ICR.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2021	36 Months From Approved
Responses	513,872	0	0
Time Burden (Hours)	1,000,167	0	0
Cost Burden (Dollars)	0	0	0

Authorizing Statute(s): US Code: 5 USC 522(b)(4) Name of Law: The Freedom of Information Act
   US Code: 26 USC 501(c) Name of Law: List of Tax Exempt Organizations
   US Code: 26 USC 3402(t) Name of Law: Income Tax Collected At Source
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.500 Name of Law: Requirements for Establishing and Maintaining Medicare Billing Privileges
   US Code: 42 USC 424.502 Name of Law: Definitions
   US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	513,872	513,872
Annual Time Burden (Hours)	1,000,167	1,000,167
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection of information. The burden hours associated with this data collection is 1,000,167 hours.

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Jamaa Hill 301 492-4190

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