Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)

Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers (Form 855S)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1056 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-855S Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222) Form and Instruction
CMS-855S Medicare Durable Medical Equipment Supplier Enrollment A cms855s.pdf Form and Instruction
CMS-855S Medicare Enrollment Application: Durable Medical Equipme 855 PECOS Screen Shots for OSORA (1).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Enrollment of MA Providers, Suppliers, and First-Tier, Downstream, and Related Entities (FDRs) (section 422.222)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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-855S	Medicare Enrollment Application: Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers	855 PECOS Screen Shots for OSORA (1).docx		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-855S	Medicare Durable Medical Equipment Supplier Enrollment Application	cms855s.pdf		No		Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 10,666	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	-10,666	10,666
Annual IC Time Burden (Hours)	-42,664	42,664
Annual IC Cost Burden (Dollars)	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.