Medicare EDI Enrollment Form and EDI Registration

Medicare EDI Enrollment Form and EDI Registration (CMS-10164 A/B)

Documents and Forms

Document Name Document Type
Form CMS-10164A Medicare EDI Enrollment Form and EDI Registration Form
CMS-10164A CMS-10164A CMS10164A.pdf Form
CMS-10164A CMS-10164A CMS10164A.pdf Form
CMS10164B CMS10164B CMS10164B.pdf Form
CMS10164B CMS10164B CMS10164B.pdf Form

Information Collection (IC) Details

IC Title:	Medicare EDI Enrollment Form and EDI Registration	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 42 CFR 162

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10164A	CMS-10164A	CMS10164A.pdf		Yes	Yes	Fillable Fileable
Form	CMS10164B	CMS10164B	CMS10164B.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,181,209	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	1,181,209	987,941	193,268
Annual IC Time Burden (Hours)	393,736	329,313	64,423
Annual IC Cost Burden (Dollars)	0	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.