Information Collection

Submitter Application and Instructions

IC 225026 under ICR 202403-0938-009 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CMS-10340 Submitter Application and Instructions Form and Instruction
CMS-10340 CSSC Operations Submitter Application (Form and Instruct 12_2_2 Submitter Application with OMB [rev OSORA PRA] (4).docx Form and Instruction
CMS-10340 CSSC Operations Submitter Application (Form and Instruct 12_2_2 Submitter Application with OMB [rev OSORA PRA] (4).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Submitter Application and Instructions	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 and Instruction	CMS-10340	CSSC Operations Submitter Application (Form and Instruction)	12_2_2 Submitter Application with OMB [rev OSORA PRA] (4).docx		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: 19	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 Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	19	-31	50
Annual IC Time Burden (Hours)	3	-4	7
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.