4120-01-U-P
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[Document Identifiers: CMS-855B]
Agency Information Collection Activities: Proposed Collection; 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
60 days for public comment on the proposed action. Interested persons are invited to send
comments regarding our burden estimates 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 must be received by [INSERT DATE 60 DAYS AFTER DATE OF
PUBLICATION IN THE FEDERAL REGISTER].
ADDRESSES: When commenting, please reference the document identifier or OMB control
number. To be assured consideration, comments and recommendations must be submitted in any
one of the following ways:

1. Electronically. You may send your comments electronically to
http://www.regulations.gov. Follow the instructions for "Comment or Submission" or "More
Search Options" to find the information collection document(s) that are accepting comments.
2. By regular mail. You may mail written comments to the following address:
CMS, Office of Strategic Operations and Regulatory Affairs
Division of Regulations Development
Attention: Document Identifier/OMB Control Number: 
Room C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850.
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 N. Parham at (410) 786-4669.
SUPPLEMENTARY INFORMATION:
Contents
This notice sets out a summary of the use and burden associated with the following
information collections. More detailed information can be found in each collection’s supporting
statement and associated materials (see ADDRESSES).
CMS-855B

Medicare Enrollment Application for Clinics/Group Practices and Other Suppliers

Under the 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

requires Federal agencies to publish a 60-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.
Information Collections
1.

Type of Information Collection Request: Reinstatement with change of a

previously approved collection; Title of Information Collection: Medicare Enrollment
Application for Clinics/Group Practices and Other Suppliers; Use: Various sections of the Act,
the United States Code (U.S.C.), Internal Revenue Service (IRS) Code, and the 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 Form CMS-855B application is submitted when the applicant first requests Medicare
enrollment. The application is used by the MACs to collect data to ensure the applicant has the
necessary credentials to provide the health care services for which they intend to bill Medicare;
this includes data that allows the Medicare contractor to correctly price, process, and pay the
applicant’s claims. It also gathers information that enables MACs to ensure that the supplier is
neither excluded from the Medicare program nor debarred, suspended, or excluded from any
other Federal agency or program. The application is also used by enrolled suppliers when they
are reporting a change in their ownership, a change in their current Medicare enrollment
information, or are revalidating or reactivating their Medicare enrollment. Form Number: CMS855B (OMB control number: 0938-1377); Frequency: Occasionally; Affected Public: Private
Sector; Business or other for-profits, and Not-for Profits; Number of Respondents: 132,800;
Number of Responses: 132,800; Total Annual Hours: 155,884. (For questions regarding this
collection, contact Frank Whalen at 410-786-1302 or Frank.Whelan@cms.hhs.gov.)
William N. Parham, III,
Director,

Division of Information Collections and Regulatory Impacts,
Office of Strategic Operations and Regulatory Affairs.
[FR Doc. 2024-14955 Filed: 7/8/2024 8:45 am; Publication Date: 7/9/2024]