REH Completion of CMS-855A Change of Information

Medicare Enrollment Application for Institutional Providers (CMS-855A)

Documents and Forms

Document Name Document Type
Form CMS-855A REH Completion of CMS-855A Change of Information Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A- Medicare Enrollment Application Institutional Providers.pdf Form and Instruction
CMS-855A Medicare Enrollment Application - Institutional Provider CMS-855A- Medicare Enrollment Application Institutional Providers.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	REH Completion of CMS-855A Change of Information	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-855A	Medicare Enrollment Application - Institutional Providers	CMS-855A- Medicare Enrollment Application Institutional Providers.pdf		Yes	No	Fillable Fileable Signable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23	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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	23	23
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.