4120-01-U-P
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers: CMS-855A]
Agency Information Collection Activities: Submission for OMB Review; Comment Request
AGENCY: Centers for Medicare & Medicaid Services, Health and Human Services (HHS).
ACTION: Notice.
SUMMARY: The Centers for Medicare & Medicaid Services (CMS) is announcing an
opportunity for the public to comment on CMS’ intention to collect information from the public.
Under the Paperwork Reduction Act of 1995 (PRA), Federal agencies are required to publish
notice in the Federal Register concerning each proposed collection of information, including
each proposed extension or reinstatement of an existing collection of information, and to allow a
second opportunity for public comment on the notice. Interested persons are invited to send
comments regarding the burden estimate or any other aspect of this collection of information,
including the necessity and utility of the proposed information collection for the proper
performance of the agency’s functions, the accuracy of the estimated burden, ways to enhance
the quality, utility, and clarity of the information to be collected, and the use of automated
collection techniques or other forms of information technology to minimize the information
collection burden.
DATES: Comments on the collection(s) of information must be received by the OMB desk
officer by [INSERT DATE 30 DAYS AFTER DATE OF PUBLICATION IN THE
FEDERAL REGISTER].
ADDRESSES: Written comments and recommendations for the proposed information
collection should be sent within 30 days of publication of this notice to
www.reginfo.gov/public/do/PRAMain . Find this particular information collection by selecting
"Currently under 30-day Review - Open for Public Comments" or by using the search function.

To obtain copies of a supporting statement and any related forms for the proposed
collection(s) summarized in this notice, please access the CMS PRA web site by copying and
pasting the following web address into your web browser: https://www.cms.gov/Regulationsand-Guidance/Legislation/PaperworkReductionActof1995/PRA-Listing
FOR FURTHER INFORMATION CONTACT: William Parham at (410) 786-4669.
SUPPLEMENTARY INFORMATION: Under the Paperwork Reduction Act of 1995 (PRA)
(44 U.S.C. 3501-3520), Federal agencies must obtain approval from the Office of Management
and Budget (OMB) for each collection of information they conduct or sponsor. The term
“collection of information” is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes
agency requests or requirements that members of the public submit reports, keep records, or
provide information to a third party. Section 3506(c)(2)(A) of the PRA (44 U.S.C.
3506(c)(2)(A)) requires Federal agencies to publish a 30-day notice in the Federal Register
concerning each proposed collection of information, including each proposed extension or
reinstatement of an existing collection of information, before submitting the collection to OMB
for approval. To comply with this requirement, CMS is publishing this notice that summarizes
the following proposed collection(s) of information for public comment:
1.

Type of Information Collection Request: Revision of a currently approved

collection; Title of Information Collection: Medicare Enrollment Application for Institutional
Providers; Use: Various sections of the Social Security Act (Act), the United States Code
(U.S.C.), Internal Revenue Service Code (Code) and the Code of Federal Regulations (CFR)
require providers and suppliers to furnish information concerning the amounts due and the
identification of individuals or entities that furnish medical services to beneficiaries before
payment can be made.
The primary function of the CMS-855A Medicare enrollment application is to gather
information from a certified provider or certified supplier (hereafter occasionally and collectively
referenced as “provider(s)”) that tells us who it is, whether it meets certain qualifications to be a

health care provider, where it practices or renders services, the identity of its owners, and other
information necessary to establish correct claims payments. Form Number: CMS-855A (OMB
control number: 0938-0685); Frequency: On occasion; Affected Public: Business or other forprofits, not-for-profit institutions; Number of Respondents: 45,473; Total Annual Responses:
217,493; Total Annual Hours: 41,120. (For policy questions regarding this collection contact
Frank Whelan at 410-786-1302.)
William N. Parham, III
Director,
Division of Information Collections and Regulatory Impacts,
Office of Strategic Operations and Regulatory Affairs.

[FR Doc. 2024-14637 Filed: 7/2/2024 8:45 am; Publication Date: 7/3/2024]