Information Collection

Medicare EDI Enrollment Form and EDI Registration

IC 8845 under ICR 202405-0938-014 · OMB 0938-0983.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-0983 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

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.