OMB control number

Medicare Enrollment Application for Clinics/ Group Practice and Certain Other Suppliers

OMB 0938-1198 · HHS/CMS.

OMB 0938-1198

Latest Forms, Documents, and Supporting Material

Document Name
Form CMS-855B Change of Information Form and Instruction
Form CMS-855B Revalidation of Enrollment Form and Instruction
Form CMS-855B Initial Enrollment Form and Instruction
855B PECOS Screen Shots for PRA Package - 04192012.DOCX Supplementary Document
CMS 855B - Revisons Spreadsheet - 04182012.xlsx Supplementary Document
CMS 855B - section mapping - 04182012.xlsx Supplementary Document
CMS-855B Supporting Statement.docx Supporting Statement A
Change of Information Form and Instruction
Revalidation of Enrollment Form and Instruction
Initial Enrollment Form and Instruction

All Historical Document Collections

201302-0938-005

2013-02-12