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OMB Control No: 0938-1355	ICR Reference No: 202603-0938-001
Status: Received in OIRA	Previous ICR Reference No: 202301-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 03/03/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	813,975	812,975
Time Burden (Hours)	1,364,719	1,355,310
Cost Burden (Dollars)	0	0

Authorizing Statute(s): US Code: 42 USC 424.500 Name of Law: Requirements for Establishing and Maintaining Medicare Billing Privileges
   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 424.502 Name of Law: Definitions
   US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number
   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

Citations for New Statutory Requirements: None

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	813,975	812,975	1,000
Annual Time Burden (Hours)	1,364,719	1,355,310	9,409
Annual Cost Burden (Dollars)	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Change in burden due to overestimation and underestimation of enrollment application use among the public.

Annual Cost to Federal Government: $3,929

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? No

Agency Contact: Malcolm Wilson 667 414-0087 malcolm.wilson@cms.hhs.gov

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