Information Collection

Establishing or adding a reassignment of benefits enrollment application

IC 202866 under ICR 201906-0938-008 · OMB 0938-1179.

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 - Medicare Enrollment 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 - Medicare Enrollment 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: 307,730	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	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	307,730	-28,014	335,744
Annual IC Time Burden (Hours)	76,933	-7,003	83,936
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.