Medicare Enrollment Application (Form 855S)

Forms and Documents

Document Name	Status
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15) Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12) Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9) Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6) Form	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4) Form	New
CMS-855(S) Supporting Statement - CLEAN Version - 02022009.doc Supporting Statement A	2009-02-25

IC Document Collections

IC ID	Document Title	Status
188186	Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application Form	New
188184	Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information Form	New
188183	Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information Form	New
188182	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15) Form	New
188181	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12) Form	New
188180	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9) Form	New
188179	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6) Form	New
186782	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4) Form	New

ICR Details

OMB Control No: 0938-1056	ICR Reference No: 200810-0938-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application (Form 855S)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/16/2009
	Date Received in OIRA: 10/01/2008
Terms of Clearance: This ICR is approved consistent with revised supporting statement and burden estimates.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2012	36 Months From Approved
Responses	149,290	0	0
Time Burden (Hours)	331,620	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The primary function of the CMS 855S DMEPOS supplier enrollment application is to gather information from a supplier that tells us who it is, whether it meets certain qualifications to be a health care supplier, where it renders its services or supplies, the identity of the owners of the enrolling entity, and information necessary to establish the correct claims payment. The goal of evaluating and revising the CMS 855S DMEPOS supplier enrollment application is to simplify and clarify the information collection without jeopardizing our need to collect specific information. Additionally, periodic revisions are necessary to incorporate new regulatory requirements. CMS is also revising the CMS-855 Medicare Enrollment Applications Package (OMB No. 0938-0685) to remove the CMS-855S application from its collection.

---

Authorizing Statute(s): US Code: 42 USC 1395f Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395g Name of Law: Requirements of Requests and Certifications
   US Code: 42 USC 1395cc Name of Law: AGREEMENTS WITH PROVIDERS OF SERVICES; ENROLLMENT PROCESSES
   US Code: 42 USC 1395m Name of Law: SPECIAL PAYMENT RULES FOR PARTICULAR ITEMS AND SERVICES
   PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997
   PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 31120	05/30/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 49677	08/22/2008
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4)	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9)	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12)	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15)	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application	CMS-855S	CMS-855S
Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6)	CMS-855S	CMS-855S

---

ICR Summary of Burden

	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	149,290	0	0	149,290	0	0
Annual Time Burden (Hours)	331,620	0	0	331,620	0	0
Annual Cost Burden (Dollars)	0	0	0	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: No

Burden Reduction Due to:

Short Statement: This is a new collection. Previously the form CMS-855S was associated with the OMB control number 0938-0685. However, we are seeking a new number for only the CMS-855S.

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/01/2008

---