Information Collection

Electronic Data Interchange (EDI) Agreement

IC 225025 under ICR 202502-0938-001 · OMB 0938-1152.

Documents and Forms

Document Name Document Type
Form CMS-10340 Electronic Data Interchange (EDI) Agreement Form
CMS-10340 MAO Electronic Data Interchange (EDI) Agreement EDI Agreement with OMB a08112020.pdf Form
CMS-10340 MAO Electronic Data Interchange (EDI) Agreement EDI Agreement with OMB a08112020.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Electronic Data Interchange (EDI) Agreement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CMS-10340	MAO Electronic Data Interchange (EDI) Agreement	EDI Agreement with OMB a08112020.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title: CMS Encounter Data System (EDS)	FR Citation: 83 FR 6591

Number of Respondents: 201	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	201	201
Annual IC Time Burden (Hours)	17	17
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.