Information Collection Request

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

ICR 202301-0938-009 · OMB 0938-1355 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-1355 can be found here:

Forms and Documents

Document Name	Status
Form CMS-855i Voluntary Termination of Medicare Enrollment Form and Instruction	Modified
Form CMS-855i Reporting a Change Form and Instruction	Modified
Form CMS-855i Switching Provider Type/MAC Form and Instruction	Modified
Form CMS-855I Revalidation Form and Instruction	Modified
Form CMS-855i Reactivation Form and Instruction	Modified
Form CMS-855i Initial Enrollment Form and Instruction	Modified
CMS-855I Supporting Statement.docx Supporting Statement A	2023-02-28

IC Document Collections

IC ID	Document Title	Status
232330	Voluntary Termination of Medicare Enrollment Form and Instruction	Modified
232329	Reporting a Change Form and Instruction	Modified
232320	Switching Provider Type/MAC Form and Instruction	Modified
232319	Revalidation Form and Instruction	Modified
232318	Reactivation Form and Instruction	Modified
232317	Initial Enrollment Form and Instruction	Modified

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-1355
Type of Information Collection	Reinstatement without change of a previously approved collection
Previous ICR Reference No	201807-0938-006
Agency Tracking No	CPI
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31