Electronic Submission

ADA Dental Claim Form (CMS-10883)

Documents and Forms

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

Information Collection (IC) Details

IC Title:	Electronic Submission	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:

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 %

	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

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.