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Medicare EDI Enrollment Form and EDI Registration
Medicare EDI Enrollment Form and EDI Registration (CMS-10164 A/B)
OMB: 0938-0983
IC ID: 8845
OMB.report
HHS/CMS
OMB 0938-0983
ICR 202602-0938-017
IC 8845
( )
Documents and Forms
Document Name
Document Type
no available documents/forms check other ICs listed under this ICR
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Medicare EDI Enrollment Form and EDI Registration
Agency IC Tracking Number:
OIT
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
42 CFR 162
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
CMS-10164 A
CMS EDI Enrollment Registration Form
10164A_CMS-EDI-Registration-Form.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10164 B
CMS EDI Enrollment Agreement Form
10164B_CMS EDI Enrollment Agreement Form.pdf
Yes
Yes
Fillable Fileable
Form and Instruction
CMS-10164 C
CMS-EDI Enrollment Attestation Form
10164C_CMS-EDI-Enrollment-Attestation-Form.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Health Care Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
229,767
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 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
229,767
0
-951,442
0
0
1,181,209
Annual IC Time Burden (Hours)
153,178
0
-240,558
0
0
393,736
Annual IC Cost Burden (Dollars)
0
0
0
0
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.
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