Medicare Enrollment Application (Form 855S)

Forms and Documents

Document Name	Status
Form CMS-855(S) Surety Bond Compliance Form and Instruction	New
Form CMS-855(S) Revalidation of enrollment information, Form and Instruction	New
Form CMS-855(S) Change of Enrollment Information Form and Instruction	New
Form CMS-855(S) Initial Enrollment Form and Instruction	New
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15) Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12) Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9) Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6) Form	Removed
Form CMS-855S Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4) Form	Removed
CMS-855S.Response to Public Comments (06282011).doc Supplementary Document	2011-06-30
CMS 855S Supporting Statement (7-1-11).doc Supporting Statement A	2011-07-01

IC Document Collections

IC ID	Document Title	Status
197903	Surety Bond Compliance Form and Instruction	New
197902	Revalidation of enrollment information, Form and Instruction	New
197901	Change of Enrollment Information Form and Instruction	New
197900	Initial Enrollment Form and Instruction	New
188186	Medicare Enrollment Application (Form 855S) - Part II - Initial Enrollment Application Form	Removed
188184	Medicare Enrollment Application (Form 855S) - Part II - Revalidation of Enrollment Information Form	Removed
188183	Medicare Enrollment Application (Form 855S) - Part II - Reporting Changes of Enrollment Information Form	Removed
188182	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(15) Form	Removed
188181	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(12) Form	Removed
188180	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(9) Form	Removed
188179	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(6) Form	Removed
186782	Medicare Enrollment Application (Form 855S) - Part II - 424.57(d)(2)through(d)(4) Form	Removed

ICR Details

OMB Control No: 0938-1056	ICR Reference No: 201105-0938-016
Status: Historical Active	Previous ICR Reference No: 200810-0938-001
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Medicare Enrollment Application (Form 855S)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/01/2011
	Date Received in OIRA: 05/31/2011
Terms of Clearance: In accordance with 5 CFR 1320, the information collection is approved. The approval currently extends only to the mode of collection (paper based form) contained in this request.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2014	36 Months From Approved	03/31/2012
Responses	140,290	0	149,290
Time Burden (Hours)	331,620	0	331,620
Cost Burden (Dollars)	0	0	0

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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, periodically new congressional legislation requires CMS to update the Medicare Provider Enrollment Applications (CMS 855s). Recently approved/passed legislation requires CMS to make slight revisions to the CMS 855S application. The majority of these changes are very minor in nature such as a question with a "Yes/No" check box, spelling and formatting corrections, removal of duplicate fields, instruction clarification for the DMEPOS supplier and indicating services rendered from check lists.

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Authorizing Statute(s): PL: Pub.L. 104 - 134 31001(I) Name of Law: Debt Collection Improvement Act of 1996
   PL: Pub.L. 105 - 33 4313 Name of Law: Balanced Budget Act of 1997
   US Code: 42 USC 1395l Name of Law: Payment of Benefits
   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
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 13415	03/11/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 29247	05/20/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Change of Enrollment Information	CMS-855(S)	Medicare Durable Medical Equipment Supplier Enrollment Application
Revalidation of enrollment information,	CMS-855(S)	Medicare Durable Medical Equipment Supplier Enrollment Application
Surety Bond Compliance	CMS-855(S)	Medicare Durable Medical Equipment Supplier Enrollment Application
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
Initial Enrollment	CMS-855(S)	Medicare Durable Medical Equipment Supplier Enrollment Application

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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	140,290	149,290	0	-9,000	0	0
Annual Time Burden (Hours)	331,620	331,620	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The revisions contained in this submission do not affect the currently approved burden estimates. The current total annual burden associated with this information collection is approximately 331,619.5 hours. The total individual burden associated with this information collection is approximately 9 hours per initial application.

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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]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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: 05/31/2011

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