Information Collection Request

Medicare Enrollment Application for Institutional Providers (CMS-855A)

ICR 202305-0938-003 · OMB 0938-0685 · Received in OIRA

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0938-0685 can be found here:

Forms and Documents

Document Name	Status
Form CMS-855A Medicare Enrollment Application for Institutional Providers Form and Instruction	Modified
Form CMS-855A REH Completion of CMS-855A Change of Information Form and Instruction	New
CMS-855A - Responses to 60-day comments.docx Supplementary Document	2023-05-05
CMS-855A - Crosswalk Revisions Spreadsheet.xlsx Supplementary Document	2023-05-05
CMS-855A - Supporting Statement Part A (30-day).docx Supporting Statement A	2023-05-05

IC Document Collections

IC ID	Document Title	Status
8284	Medicare Enrollment Application for Institutional Providers Form and Instruction	Modified
260074	REH Completion of CMS-855A Change of Information Form and Instruction	New

ICR Details

Status	Received in OIRA
Agency/Subagency	HHS/CMS
OMB Control No	0938-0685
Type of Information Collection	Reinstatement with change of a previously approved collection
Previous ICR Reference No	202103-0938-010
Agency Tracking No	CPI
Date Submitted to OIRA	1969-12-31
Requested Expiration Date	1969-12-31