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

ICR 202301-0938-009

OMB: 0938-1355

Federal Form Document

Forms and Documents

Document Name	Status
Form CMS-855i Voluntary Termination of Medicare Enrollment Form and Instruction	Modified
Form CMS-855i Reporting a Change Form and Instruction	Modified
Form CMS-855i Switching Provider Type/MAC Form and Instruction	Modified
Form CMS-855I Revalidation Form and Instruction	Modified
Form CMS-855i Reactivation Form and Instruction	Modified
Form CMS-855i Initial Enrollment Form and Instruction	Modified
CMS-855I Supporting Statement.docx Supporting Statement A	2023-02-28

IC Document Collections

IC ID	Document Title	Status
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