Information Collection

Medicare EDI Enrollment Form and EDI Registration

IC 8845 under ICR 201302-0938-010 · OMB 0938-0983.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0983 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10164 Medicare EDI Enrollment Form and EDI Registration	Form and Instruction
CMS-10164 Accesible EDI Registration Form CMS-10164_Medicare_EDI_Registration_(7-31-12)_v2.pdf	Form and Instruction
CMS-10164 Accessible EDI Enrollment Form CMS-10164_EDI_ENROLL(8-8-12).pdf	Form and Instruction

IC Title:

Medicare EDI Enrollment Form and EDI Registration

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 162

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-10164	Accesible EDI Registration Form	CMS-10164_Medicare_EDI_Registration_(7-31-12)_v2.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	CMS-10164	Accessible EDI Enrollment Form	CMS-10164_EDI_ENROLL(8-8-12).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 240,000

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 Potential Violation of the PRA
Annual Number of Responses for this IC	240,000	240,000
Annual IC Time Burden (Hours)	80,000	80,000
Annual IC Cost Burden (Dollars)	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.