Electronic Health Record Demonstration

Electronic Health Record Demonstration

OMB: 0938-0965

IC ID: 8825

Information Collection (IC) Details

View Information Collection (IC)

Electronic Health Record Demonstration
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction CMS-10165 Electronic Health Record (EHR) Demonstration Application to Participate CMS-10165 (6)_final.pdf Yes Yes Paper Only

Health Health Care Services

 

2,400 2,400
   
Private Sector Businesses or other for-profits
 
   83 %

  Approved 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 2,400 0 1,600 0 0 800
Annual IC Time Burden (Hours) 520 0 387 0 0 133
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
CMS-10165 Description of Changes to Form_FINAL CMS-10165 Description of Changes to Form_FINAL.doc 02/20/2008
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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