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

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
279274	Currently Enrolled via CMS-855O now Enrolling as Individual Supplier Form and Instruction	New
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

OMB Control No: 0938-1355	ICR Reference No: 202603-0938-001
Status: Received in OIRA	Previous ICR Reference No: 202301-0938-009
Agency/Subagency: HHS/CMS	Agency Tracking No: CPI
Title: Medicare Enrollment Application for Physician and Non-Physician Practitioners (CMS-855I)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/03/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	05/31/2026
Responses	813,975	812,975
Time Burden (Hours)	1,364,719	1,355,310
Cost Burden (Dollars)	0	0

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Abstract: The primary function of the CMS-855I Medicare enrollment application for physicians and non-physician practitioners is to gather information from an individual provider or supplier that tells us who he/she is, whether he/she meets certain qualifications to be a Medicare health care provider or supplier, where he/she practices or renders services, and other information necessary to establish correct claims payments.

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Authorizing Statute(s): US Code: 42 USC 424.500 Name of Law: Requirements for Establishing and Maintaining Medicare Billing Privileges
   PL: Pub.L. 109 - 220 508 Name of Law: Rehabilitation Act of 1973 as incorporated with the Americans With Disabilities Act of 2005
   US Code: 42 USC 424.502 Name of Law: Definitions
   US Code: 31 USC 7701(c) Name of Law: Tax Payer Identification Number
   US Code: 5 USC 522(b)(4) Name of Law: The Freedom of Information Act
   US Code: 26 USC 501(c) Name of Law: List of Tax Exempt Organizations
   US Code: 26 USC 3402(t) Name of Law: Income Tax Collected At Source
   EO: EO 12600 Name/Subject of EO: Predisclosure Notification Procedures for Confidential Commercial Information
  

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:
	90 FR 58247	12/16/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 10095	03/02/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
Currently Enrolled via CMS-855O now Enrolling as Individual Supplier	CMS-855I	Medicare Enrollment Application
Initial Enrollment	CMS-855I	Medicare Enrollment Application
Reactivation	CMS-855I	Medicare Enrollment Application
Reporting a Change	CMS-855I	Medicare Enrollment Application
Revalidation	CMS-855I	Medicare Enrollment Application
Switching Provider Type/MAC	CMS-855I	Medicare Enrollment Application
Voluntary Termination of Medicare Enrollment	CMS-855I	Medicare Enrollment Application

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ICR Summary of Burden

	Total Request	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	813,975	812,975	0	1,000	0	0
Annual Time Burden (Hours)	1,364,719	1,355,310	0	9,409	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: Change in burden due to overestimation and underestimation of enrollment application use among the public.

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Annual Cost to Federal Government: $3,929

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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? No

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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: 03/03/2026

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