Medicare EDI Enrollment Form and EDI Registration

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.