OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medicare Enrollment Application- Reassignment of Medicare Benefits

ICR 201206-0938-007 · OMB 0938-1179 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-855R Terminating a Reassignment Form and Instruction New Repair queued
Form CMS-855R Establishing a reassignment of benefits enrollment application Form and Instruction New Available
CMS 855R - Revisons Spreadsheet - 01052012.xlsx Supplementary Document Uploaded 2012-06-22 Repair queued
CMS 855R - section mapping - 01112012.xlsx Supplementary Document Uploaded 2012-06-22 Available
CMS-855R Supporting Statement Part A.docx Supporting Statement A Uploaded 2012-06-22 Available
IC Document Collections
IC IDCollectionTypeStatusForm
202867 Terminating a Reassignment Form and Instruction New
202866 Establishing a reassignment of benefits enrollment application Form and Instruction New
ICR Details
0938-1179 201206-0938-007
Historical Active
HHS/CMS
Medicare Enrollment Application- Reassignment of Medicare Benefits
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 11/01/2012
Retrieve Notice of Action (NOA) 06/25/2012
  Inventory as of this Action Requested Previously Approved
11/30/2015 36 Months From Approved
200,000 0 0
50,000 0 0
0 0 0
The primary function of the CMS 855R enrollment application is to allow physicians and non-physician practitioners to reassign their Medicare benefits to a group practice and to gather information from the individual that tells us who he/she is, where he or she renders services, and information necessary to establish correct claims payment. The goal of evaluating and revising the CMS 855R enrollment application is to require the physician or non-physician practitioner to identify a primary group location where the physician or non-physician practitioner will render most of his or her services. This identification does not add any additional burden to the physicians or non-physician practitioners.
None
None
Not associated with rulemaking
  77 FR 4564 01/30/2012
77 FR 35982 06/15/2012
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 200,000 0 0 200,000 0 0
Annual Time Burden (Hours) 50,000 0 0 50,000 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new information collection request.
$0
No
No
No
No
No
Uncollected
William Parham 4107864669
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
06/25/2012