Information Collection

Electronic Health Record Demonstration

IC 8825 under ICR 200803-0938-001 · OMB 0938-0965.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0965 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10165 Electronic Health Record Demonstration	Form and Instruction
CMS-10165 Electronic Health Record (EHR) Demonstration Application CMS-10165 (6)_final.pdf	Form and Instruction
CMS-10165 Description of Changes to Form_FINAL.doc CMS-10165 Description of Changes to Form_FINAL	IC Document

IC Title:

Electronic Health Record Demonstration

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
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

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 2,400

Number of Respondents for Small Entity: 2,400

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 83 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	2,400	1,600	800
Annual IC Time Burden (Hours)	520	387	133
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.