Electronic Health Record Demonstration

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.