Submitter Authorization Form

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

Documents and Forms

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

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 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 %

	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

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.