Submitter Authorization Form

Collection of Encounter Data from MA Organizations, Section 1876 Cost HMOs/CMPs, MMPs, and PACE Organizations (CMS-10340)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1152 can be found here:

Documents and Forms

Document Name Document Type
Form CMS-10340 Submitter Authorization Form Form
CMS-10340 CSSC Operations Submitter Authorization Form Submitter Authorization 01082021 v2.pdf Form

Information Collection (IC) Details

IC Title:	Submitter Authorization Form	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	CMS-10340	CSSC Operations Submitter Authorization Form	Submitter Authorization 01082021 v2.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: CMS Encounter Data System (EDS)	FR Citation: 83 FR 6591

Number of Respondents: 430	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	430	-261	691
Annual IC Time Burden (Hours)	72	-101	173
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.