Paper Submission

ADA Dental Claim Form (CMS-10883)

Documents and Forms

Document Name Document Type
Form CMS-10883 Paper Submission 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:	Paper Submission	Agency IC Tracking Number:

Is this a Common Form? Yes		IC Status: New

Obligation to Respond: Mandatory

CFR Citation: 42 CFR 425(a)(5) (To search for a specific CFR, visit the Code of Federal Regulations.)

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: 50,000	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 14 %

	Approved	Program Change Due to New Statute
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	12,500	12,500
Annual IC Cost Burden (Dollars)	44,000	44,000

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.