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Change of Enrollment Information
Medicare Enrollment Application (Form 855S)
OMB: 0938-1056
IC ID: 197901
OMB.report
HHS/CMS
OMB 0938-1056
ICR 201210-0938-010
IC 197901
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1056 can be found here:
2023-09-20 - Revision of a currently approved collection
2022-01-11 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form CMS-855-S
Change of Enrollment Information
Form and Instruction
CMS-855(S) Medicare Durable Medical Equipment Supplier Enrollment A
CMS-855S(6-30-11).pdf
Form and Instruction
CMS-855S Medicare Durable Medical Equipment Supplier Enrollment A
CMS-855S.pdf
Form and Instruction
CMS-855-S Medicare Enrollment Application: Durable Medical Equipme
855 PECOS Screen Shots for OSORA.docx
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Change of Enrollment Information
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Mandatory
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-855-S
Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers
855 PECOS Screen Shots for OSORA.docx
Yes
No
Fillable Fileable
Form and Instruction
CMS-855(S)
Medicare Durable Medical Equipment Supplier Enrollment Application
CMS-855S(6-30-11).pdf
Yes
No
Fillable Fileable
Form and Instruction
CMS-855S
Medicare Durable Medical Equipment Supplier Enrollment Application
CMS-855S.pdf
Yes
No
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
17,100
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits, Not-for-profit institutions
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
17,100
0
-18,200
0
0
35,300
Annual IC Time Burden (Hours)
8,550
0
-9,100
0
0
17,650
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.