Submitter Authorization Form

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

OMB: 0938-1152

IC ID: 225027

Information Collection (IC) Details

View Information Collection (IC)

Submitter Authorization Form
 
No Modified
 
Required to Obtain or Retain Benefits
 

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

Health Health Care Services

CMS Encounter Data System (EDS)  83 FR 6591

430 0
   
Private Sector Businesses or other for-profits
 
   100 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 430 0 0 -261 0 691
Annual IC Time Burden (Hours) 72 0 0 -101 0 173
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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