OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medicare Enrollment Application for Physician and Non-Physician Practitioners; (CMS-855i)

ICR 201807-0938-006 · OMB 0938-1355 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form CMS-855i Voluntary Termination of Medicare Enrollment Form and Instruction New Repair queued
Form CMS-855i Reporting a Change of Medicare Enrollment Information Form and Instruction New Repair queued
Form CMS-855i Switching Provider Type/MAC Form and Instruction New Available
Form CMS-855I Revalidation Form and Instruction New Available
Form CMS-855i Reactivation Form and Instruction New Repair queued
Form CMS-855i Initial Enrollment Form and Instruction New Available
CMS-855I Supporting Statement 60-day NEW 72518.docx Supporting Statement A Uploaded 2018-07-25 Available
IC Document Collections
IC IDCollectionTypeStatusForm
232330 Voluntary Termination of Medicare Enrollment Form and Instruction New
232329 Reporting a Change of Medicare Enrollment Information Form and Instruction New
232320 Switching Provider Type/MAC Form and Instruction New
232319 Revalidation Form and Instruction New
232318 Reactivation Form and Instruction New
232317 Initial Enrollment Form and Instruction New
ICR Details
0938-1355 201807-0938-006
Active
HHS/CMS
Medicare Enrollment Application for Physician and Non-Physician Practitioners; (CMS-855i)
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 12/06/2018
Retrieve Notice of Action (NOA) 08/02/2018
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
12/31/2021 36 Months From Approved
513,872 0 0
1,000,167 0 0
0 0 0
The primary function of the CMS-855I Medicare enrollment application for physicians and non-physician practitioners is to gather information from an individual provider or supplier that tells us who he/she is, whether he/she meets certain qualifications to be a Medicare health care provider or supplier, where he/she practices or renders services, and other information necessary to establish correct claims payments.
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
   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
  
None
Not associated with rulemaking
  83 FR 10730 03/12/2018
83 FR 32667 07/13/2018
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 513,872 0 0 513,872 0 0
Annual Time Burden (Hours) 1,000,167 0 0 1,000,167 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new collection of information. The burden hours associated with this data collection is 1,000,167 hours.
$0
No
    Yes
    Yes
No
No
No
Uncollected
Jamaa Hill 301 492-4190
  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.
08/02/2018