Information Collection

Electronic Health Record Demonstration

IC 8825 under ICR 200806-0938-007 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Electronic Health Record (EHR) Demonstration Application Form 83 - Part I Worksheet_REVISED_FINAL61708.doc	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
Form and Instruction	CMS-10165	Electronic Health Record (EHR) Demonstration Application to Participate	Form 83 - Part I Worksheet_REVISED_FINAL61708.doc		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	Previously Approved
Annual Number of Responses for this IC	2,400	2,400
Annual IC Time Burden (Hours)	520	520
Annual IC Cost Burden (Dollars)	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.