Information Collection

Establishing or adding a reassignment of benefits enrollment application

IC 202866 under ICR 201509-0938-008 · OMB 0938-1179.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1179 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855-R Establishing or adding a reassignment of benefits enrollment application Form and Instruction
CMS-855-R Reasignment of Medicare Benefits Application CMS-855R - REASSIGNMENT OF MEDICARE BENEFITS Application.pdf Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Establishing or adding a reassignment of benefits enrollment application	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 424.500

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	CMS-855-R	Reasignment of Medicare Benefits Application	CMS-855R - REASSIGNMENT OF MEDICARE BENEFITS Application.pdf		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 335,744	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 30 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	335,744	235,744	100,000
Annual IC Time Burden (Hours)	83,936	58,936	25,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.