Information Collection

Submitter Authorization Form

IC 225027 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10340 Submitter Authorization Form	Form
CMS-10340 CSSC Operations Submitter Authorization Form Submitter Authorization 07172023 v11.pdf	Form
CMS-10340 CSSC Operations Submitter Authorization Form Submitter Authorization 07172023 v11.pdf	Form
RED LINE_Submitter Authorization 07172023 v11.pdf REDLINE_Submitter Authorization	IC Document
RED LINE_Submitter Authorization 07172023 v11.pdf REDLINE_Submitter Authorization	IC Document

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:

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 07172023 v11.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: 181

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	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	181	-249	430
Annual IC Time Burden (Hours)	30	-42	72
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
REDLINE_Submitter Authorization	RED LINE_Submitter Authorization 07172023 v11.pdf	03/14/2024

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.