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⚠️ Notice: This information collection may be referencing outdated material.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 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

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
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 %

	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

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.