Information Collection

CMS Real-Time Eligibility Agreement and MDCN Access Request

IC 8819 under ICR 200906-0938-014 · OMB 0938-0960.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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-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 %

table that charts list of burden
	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

table that charts IC Documents
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.