CMS Real-Time Eligibility Agreement and MDCN Access Request

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0960 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10157 CMS Real-Time Eligibility Agreement and MDCN Access Request Form and Instruction
CMS-10157 CMS-10157.Revised HETS Access Request Form CMS-10157.Revised HETS Access Request Form.doc Form and Instruction
CMS-10157 CMS-10157.Revised Trading Partner Agreement CMS-10157.Revised Trading Partner Agreement.doc Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	CMS Real-Time Eligibility Agreement and MDCN Access Request	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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-10157	CMS-10157.Revised HETS Access Request Form	CMS-10157.Revised HETS Access Request Form.doc		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10157	CMS-10157.Revised Trading Partner Agreement	CMS-10157.Revised Trading Partner Agreement.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,000	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,000	-120,000	122,000
Annual IC Time Burden (Hours)	500	-44,500	45,000
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.