Information Collection

Submitter Authorization Form

IC 225027 under ICR 202302-0938-015 · OMB 0938-1152.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10340 Submitter Authorization Form	Form
Form CMS-10340 Submitter Authorization Form	Form
CMS-10340 CSSC Operations Submitter Authorization Form Submitter Authorization 01082021 v2.pdf	Form
CMS-10340 CSSC Operations Submitter Authorization Form Submitter Authorization 01082021 v2.pdf	Form

IC Title:

Submitter Authorization Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

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	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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	430	430
Annual IC Time Burden (Hours)	72	72
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.