Information Collection

Electronic Submission

IC 266385 under ICR 202403-0938-016 · OMB 0938-1471.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CMS-10883 Electronic Submission	Form and Instruction
CMS-10883 ADA Dental Claim Form CMS-10883 Dental Claim Form 2024.pdf	Form and Instruction
CMS-10883 ADA Dental Claim Form CMS-10883 Dental Claim Form 2024.pdf	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 424.5(a)(5)

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 and Instruction	CMS-10883	ADA Dental Claim Form	CMS-10883 Dental Claim Form 2024.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title: Medicare Multi-Carrier Claims System (MCS) (SORN# 09-70-0501)

FR Citation: 83 FR 6591

Number of Respondents: 310,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 86 %

table that charts list of burden
	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	310,000	310,000
Annual IC Time Burden (Hours)	5,167	5,167
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.